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A SYSTEM 



OF 



CLINICAL MEDICINE. 



SYSTEM 



OF 



CLINICAL MEDICINE. 



BY 

ROBERT JAMES GRAVES, M.D., M.R.I.A., 

One of the Physicians of the Meatb Hospital and County of Dublin Infirmary; formerly Professor of the 

Institutes of Medicine; Honorary Corresponding Member of the Royal Medical Society of 

Berlin, the Imperial Medical Society of Vienna, and of the Medico-Chirurgical 

Societies of Hamburgh, Tubingen, Bruges, Montreal, etc, etc. 



WITH 



NOTES AND A SERIES OF LECTURES, 



BY W. W. GERHARD, M.D., 

Lecturer on Clinical Medicine to the University of Pennsylvania ; one of the 
Physicians to the Pennsylvania Hospital, etc., etc., etc. 



IRD AMERICAN EDITION. 




PHILADELPHIA: 
ED. BARRINGTON AND GEO. D. HASWELL. 

1848- 




^ 






[Entered, according to Act of Congress, in the year 1848, by Barrington and 
Haswell, in the Clerk's Office of the District Court for the Eastern District of Penn- 
sylvania.] 



TO WILLIAM STOKES, M.D., 

ONCE HIS PUPIL, NOW HIS COLLEAGUE, EVER HIS FRIEND, 

WHOSE WORK ON DISEASES OF THE CHEST 

HAS DESERVEDLY ACQUIRED 

A MORE THAN EUROPEAN REPUTATION ; 

AND 

TO FRIEDRICH W. OPPENHEIM, M.D., 

FORMERLY HIS FELLOW-STUDENT, 

EDITOR OF THE HAMBURGH MEDICAL JOURNAL, 

AND THE WRITER OF MANY VALUABLE SURGICAL TREATISES, 

THIS VOLUME IS DEDICATED 

BY 

THE AUTHOR. 



PREFACE 



THIRD AMERICAN EDITION. 



Since the last edition of Dr. Graves's lectures was published 
in this city, a new one, considerably enlarged, has been pub- 
lished by Dr. Graves, in Europe: from this edition the present 
one is printed. It contains the whole of the lectures, which 
make a very large volume ; but some detached papers which 
were not printed in the former editions, and were first published 
in the present one, are not reprinted. These essays the pub- 
lishers will probably issue in a separate form. The demand for a 
new edition is the best proof of the high character these lectures 
have gained in the United States, and of the very extended re- 
putation they have justly attained. 

The additional lectures, which, at the request of the publishers, 
were appended to the last edition of the work, have been revised, 
and some new matter on the subject of Typhus Fever has been 
added. The lectures were originally delivered as a part of a 
clinical course, or rather of several clinical courses, at the Phi- 
ladelphia Hospital, most of them were printed in a medical jour- 
nal some years since, but they were for the first time published 
in a collective form in the last edition of Dr. Graves's lectures. 
The only important subject on which the editor differs from 
Dr. Graves, is that of typhus fever. This has been, for some 
years, a contested point between the English and French phy- 
sicians ; in reality, however, the difference of opinion has arisen 
from one simple fact. The typhus fever of England and Ireland 
was unknown in France, at least at Paris, where the continued 
fever ha 1 been for many years confined to typhoid fever; the 
same had been the case for many years in this country until in 
the year 1836. when we had a disease similar to the genuine- 
typhus fever of the British islands. Since that time we have 



8 PREFACE TO AMERICAN EDITION. 

had many cases, imported directly from England, perfectly iden- 
tical with the same class of fevers. On the other hand, the ty- 
phoid fever of France is much less frequent in the British 
islands than on the continent, and is, to a certain extent, con- 
founded with the much more common form of typhus fever. 
Such at least seems to me to be the best explanation of the con- 
fusion which has existed in the statements of writers, relative to 
these two allied but not identical diseases. 



Philadelphia, > 

August, 1848. 5 



PREFACE. 



Having been, for many years, engaged in giving Clinical Instruction at 
the Meath and Sir Patrick Dun's Hospitals, I thought it to be my duty 
occasionally to publish the results of my observations in the form either 
of detached Essays, or successive series of Lectures ; the former were 
printed in the Dublin Hospital Reports, and the Dublin Medical Journal, 
the latter appeared in various English periodicals, but chiefly in that ex- 
cellent publication, the London Medical Gazette. Many of the detached 
papers were subsequently translated into French, German, and Italian, 
and several courses of the Lectures were published by Doctor Robley 
Dunglison, in a separate volume at Philadelphia. This has encouraged 
me not only to continue my exertions in the cultivation of practical me- 
dicine, but to revise what I had written and compress the whole within 
the limits of a single volume. It is necessary to mention that the Lec- 
tures were all originally delivered extempore, and were printed from notes 
taken by a short-hand writer. The reader being made aware of this cir- 
cumstance, will kindly make due allowance for the many imperfections 
of style, and the redundancy and repetition which occur but too frequently 
in this work. In revising the whole, I have been at more pains to im- 
prove the substance than to polish the surface, and have rigorously ex- 
cluded every assertion and conclusion which my subsequent experience 
has not verified. 

It should likewise be borne in mind that this volume has no pretensions 
to the title even of Outlines of the Practice of Physic, for many most im- 
portant diseases are not mentioned at all, none are fully described, and 
nowhere is treatment considered in all its bearings ; my object in lectur- 
iug has, in truth, been always strictly clinical, and except where the sub- 
ject was very tempting, and its discussion seemed to promise some useful 
and novel result, I have seldom allowed myself to deviate from the legi- 
timate pursuit of that object; on the subject of Fever, perhaps, I may 
appear to have enlarged far beyond the limits of my prescribed plan, but 
a very sufficient explanation of this apparent exception may be given, for 
as the w T ards of our Hospitals are never without fever cases, every suc- 
cessive season suggested some new remarks on that disease, and when 
the task of consolidating these courses of Lectures was undertaken, it be- 
came necessary to collect the various scattered observations on Fever, 
which occurred in almost every Lecture, and consequently (although many 
insulated cases of Fever, and the remarks they at the time called forth, 



10 PREFACE. 

have been omitted), when the materials already printed on that important 
affection were arranged in a certain connected order, and were elucidated 
by facts observed since their former publication, the mass of matter thus 
gradually accumulated was found to be much greater than was expected 
— still I must beg leave to remind the reader, that these Lectures are not 
intended to embrace the whole subject, even of Fever, and indeed it will 
be obvious from a cursory glance that my observations were generally 
dictated by some case actually under treatment, and were not intended to 
constitute any thing like a full and complete history of the Symptoms, 
Pathology, and Treatment of Fever. In attempting to form a continuous 
and connected series of reasoning on this disease, it became necessary not 
merely to reprint what I had published at various dates, but to remodel 
the whole, by adding much, and omitting more, and thus it has happened 
that the Lectures on Typhus in this work have assumed an entirely new 
form. For many years, several of the doctrines I promulgated respecting 
Fever, were opposed to those taught by other Lecturers and generally 
advocated by authors ; and consequently I was then obliged to dwell on 
such disputed questions at greater length than perhaps their intrinsic im- 
portance would now seem to warrant : formerly I stood almost alone in 
resisting the inflammatory theory of Fever, as successively brought into 
fashion by Armstrong, Clutterbuck, and Broussais, and my opinions re- 
specting contagion, the use of mercury, purgatives, of wine, diet, &c, 
were different from those then generally entertained : and therefore it was 
that such topics occupied so considerable a space in the original Lectures, 
and are treated of at some length in the present volume. While engaged 
in the task of preparing for the press, I have consulted many of my me- 
dical friends, both in Dublin, and the Provinces, on various subjects, and 
by this means having been enabled to avail myself of the experience of 
others where my own was deficient, much valuable information has been 
gained, and the courtesy of my professional brethren has produced com- 
munications which will no doubt be received by the public with a degree 
of favour proportioned to the gratitude the Author feels to his friends for 
their valuable assistance. Some of my readers may perhaps think, that 
the strictures my Introductory Lecture contains on the Physiological and 
Pathological Theories, founded on Liebig's chemical researches, are too 
severe, but a calm reconsideration of the subject convinced me that the 
Theories in question are calculated to retard the progress of Medical 
Science, and consequently ought to be energetically opposed. 



CONTENTS 



LECTURE I. 

IxTnonrcTOTiT Lxctube. — Proper method of studying Medicine— Importance of studying 
Chronic Diseases — Medical Schools of Edinburgh and Dublin — German method of giving 
Clinical Instruction — Its great superiority — Notice ef the new Medical Institutions, with 
remarks on the curriculum of study pursued at each — These views on Medical Education, 
strongly advocated in the Medical Gazette, &c. , Page J 7 

LECTURE II. 

Second IxTnonucTonT LFCTrRT. (for Session 1831-5}. — Proper method of studying Patho- 
logy and Physiology — Notice of the doctrines of Brown, Broussais, and Rasori— Study of 
Morbid Anatomy attended with difficulty — Doctrines of the Nomologists — How likely to lead 
to error — The Irish contributors to Medical Science . . . . .25 

LECTURE III. 

Third Introductory Lr.cTrnF. (Session 1836-7). — General Observations — Students 3re 
perplexed by the variety of subjects to which they are compelled to attend — Proper prelimi- 
nary education for those intended for the Medical Profession — Time misspent in learning 
Botanv and other collateral branches of medicine — Confusion arising from the frequent 
changing of medical terms and name? of medicine* — Chemistry throws but little liaht upon 
Physiology or Pathology — Notice of Liebig's theory of Metamorphosis — Dr. Watson sub- 
scribes to Liebig's theory — Reasons for dissenting from both — Liebig's theory of Animal 
Heat — Facts are wholly irreconcileable with Liebig's doctrines — Great responsibility con- 
nected with the teaching of Medicine in Great Britain . . . . .35 

LECTURE IV. 

Fever — General Observations — Reports of Mortality from Fever in Ireland — Dr. Cowan's 
Reports showing the comparative frequency of Fever in different parts of Great Britain — 
Opinions of Dr. Lombard — Mr. Chaihviek's inquiries — There does not appear to be any 
connection between Typhus Fever and Epizootic diseases — Principal features of the epi- 
demic described by Cheyne and Barker — Contagious nature of Typhus Fever — Dr. Christi- 
son's arguments in support of — Opinions of Dr. Perry — Importance of the study of Fever — 
Proper choice of a Nurse and Assistants — Air of a sick chamber — Necessity of attending to 
Diet,&c. &c. .......... 50 

LECTURE V. 

General treatment offerer — Dietetic management — The starvation system may produce organic 
disease — Proper food for fever patients and convalescents — Allaying of thirst — Sedatives — 
Expergefacients — Efficacy of green tea in a case of narcotism — Flagellation effectual in a 
case of poisoning with opium ... . . . . 69 

LECTURE VI. 

Treatment of Typhus Fever — Tympanitis often the consequence cf inattention to diet, or to 
overdosing with purgatives — The uses of air in the Intestines — Treatment of Tympanitis 
unaccompanied by Intestinal Inflammation — Utility of Spirit of Turpentine in such cases — 
Tympanitis with Inflammation and Congestion of Intestines — Acetate of Lead best remedy 
— Turpentine in Iritis . . . . . . . .75 



12 CONTENTS. 

LECTURE VII. 

Thirst in fever frequently dependent on the state of same internal organ — Blisters, employed 
as stimulants and evacuants, excite the vital action of the capillaries — An important remedy 
where cerebral affection is apprehended — Signs of approaching cerebral symptoms — Tartar 
emetic, solution and ointment — The latter used with success in some desperate cases 8 1 

LECTURE VIII. 

Further remarks on the treatment of Fever — Management of delirious patients — Advantages 
of tartar emetic in the form of enema — Subsultus tendinum sometimes from disturbance of 
the nervous extremities, independently of the brain or spinal cord — Vomiting and purging 
at the commencement of fever, indicative of cerebral affection — Scrofulous inflammation of 
the brain — Chronic scrofulous fever . . . . . . 90 

LECTURE IX. 

Morbid appearances after Delirium in Fever — Treatment in anticipation of cerebral symptoms 
— Great advantage of Blisters judiciously employed — Notice of the old mode of Blistering 95 

LECTURE X. 

On Epidemics — On the use of Emetics in the commencement of Fever — Not so weli adapted 
to a later period — Domestic remedies for feverish colds — These colds prove to be fevers, and 
time is lost — Protest against the abuse of purgative medicine in fever — The idea of curing 
fever by purging is absurd — Treatment where the bowels have become almost paralyzed 
after the cure of preceding diarrhoea — Venesection as a means of checking fever — Beneficial 
even within the first twelve hours after seizure by typhus — Various cautions respecting 
leeching and cupping-glasses — Mode of applying leeches when pneumonia or hepatitis 
supervenes on fever „ . „ . . . > . ,102 

LECTURE XI. 

Fever — Application of cold to the head ; particular apparatus for this — Warm applications 
recommended — Use of mercury in fever — Effects of Intemperance — Illustrations afforded by 
particular cases — Necessity of active attention to cerebral symptoms — Occasional absence of 
morbid appearance after death — Contraction and dilatation of the pupils — Coup de soleil — 
Flatulent distension accompanied by delirium, coma, &c, treated by spirit of turpentine with 
success . . . , . . . . . .111 

LECTURE XII. 

On the efficacy of tartar emetic and opium in fever, with much cerebral disturbance ; illustrated 
by cases ........... 121 

LECTURE XIII. 

On bed-sores in fever, and their treatment — Instances of fever spreading by contagion — Attack- 
ing a person whose mouth was affected by mercury — Observations on the use of tartar 
emetic in fever — An account of the manner in which it is usually employed — New views 
upon this subject — Treatment of fever with profuse sweating in the commencement — Mr. 
Cookson's case — Mr. Stephenson's case— Mr. Knott's case .... 127 

LECTURE XIV. 

General account of the spotted fever epidemic in Dublin, in 1834-5 — Its most remarkable 
features — Insidious character — Further explanation of the reasoning which led Dr. Graves 
to the discovery of the utility of tartar emetic in its latter stages . . . 135 

Further observations on the use of tartar emetic in the delirium of fever . .142 

LECTURE XV. 

Wine in fever — Dr. Stokes's researches on the state of the heart in typhus fever . 166 

LECTURE XVI. 

Case of long-continued nervous fever — Remarks on . . . . .171 

LECTURE XVII. 

Prescriptions in fever . . . . . . • . .175 



CONTENTS. 13 



LECTURE XVTII. 

Yellow Fever — Account of the yellow fever at Gibraltar — VT. Louis's researches — Yellow fever 
of Dublin — Notes of clinical lectures delivered in 1826 upon this subject — Contractility of 
efferent ducts ......... 179 

LECTURE XIX. 

Intermittent fever — Account of the Russian intermittent fever — Case of tertiana toporosa — 
Treatment of intermittent fever ....... 196 

LECTURE XX. 

Causes of catarrhal affections of the bronchial tubes — On the rales produced by bronchitis — 
Remarkable disproportion between the frequency of the pulse and the respiration — Use of 
emetics and chalybeates in chronic bronchitis — Symptoms that contraindicate chalybeates — 
Case of asthma, and treatment — St. John Long's liniment — Case of chronic cough — Re- 
marks on bronchial secretion — Expectoration never performed during sleep — Effects of 
catarrhal attack frequently recurring — Account of remedies employed — Great power of nitrate 
of potash, combined with tartar emetic in subduing inflammation — Observations on the 
secretion of air from the mucous membrane of the intestines in certain pulmonary affections 
— Efficacy of sulphur in chronic bronchitis — Sensation of tickling which precedes cough — 
Cough from worms — Hysteric cough — Pulmonary irritation from a syphilitic taint — Pulmo- 
nary irritation connected with a gouty diathesis; with a scorbutic habit ; with scrofula 201 

LECTURE XXI. 

Gangrene and Pleuritis . . . . . . . . .221 

LECTURE XXII. 

Haemoptysis — Pulmonar" Anoplexy — Phthisis — Treatment of Haemoptysis — Remarkable 
instances of recovery . ....... 229 

LECTURE XXIII. 

Pathology of Phthisis — Formation of Tubercles .... 244 

LECTURE XXIV. 

Syphilis. — Dr. Roe's Report on Syphilis — Treatment of Gonorrhoea — Mr. Hoskins on Puru- 
lent Ophthalmia ......... 260 

LECTURE XXV. 

Gonorrhoea — Injections, combined with general and local antiphlogistic means — Gonorrhoeal 
Rheumatism and Ophthalmia — Postscript ...... 269 

LECTURE XXVI. 

On the pathology and treatment of syphilis ...... 276 

LECTURE XXVII. 

Syphilis continued ......... 285 

LECTURE XXVIII. 

Different forms of syphilitic eruption— Methods of treatment — Affections of the bones- 
Memorandum of Dr. Fricke's practical observations on the nature and treatment of syphilitic 
diseases .......*.. 294 

LECTURE XXIX. 

Dr. Struntz's observations on the non-mercurial treatment of syphilis — Result of Dr. Oppen- 
heim's inquiries — Opinions of Dr. Staberoh — Further remarks on the venereal disease 307 

LECTURE XXX. 

Difference of opinion respecting the use of mercury in the venereal disease — The question 
discussed, Is it possible to cure secondary symptoms without mercury 1 — Chancres — Abuse 
of Mercury — General treatment of Syphilis — Other poisons capable of producing an eruption 
similar to syphilitic — Concluding remarks : on chancre; mode of applying caustic in venereal 
sores, &c. — Dr. Tuohill's communication on Phagedena . . . .317 



14 CONTENTS. 

LECTURE XXXI. 

Treatment of syphilis continued — Use and abase of mercury, with cases — On the causes which 
impede its beneficial action — Corrosive sublimate to be preferred in some cases — Observa- 
tions of authors, &c. . . . . . . . . 324 

LECTURE XXXII. 

Paralysis. — General remarks on the pathology of paralysis — Dr. Graves's new views upon this 
subjeet — Their application to the study of several varieties of paraplegia — Explanation of Mr. 
Stanley's cases of paraplegia ; of Dr. Stokes's cases — Two cases of paraplegia after enteritis — 
Paraplegia after metritis — Paraplegia the consequence of poisoning by lead ; by arsenfc — 
Paraplegia arising from irritation of the urethra (case communicated by Dr. Hutton) 342 

LECTURE XXXIII. 

Electro-Magnetism.^ — Mr. Clarke's communication on this subject — Cases treated by this 
agent — Mr. Clarke's remarks on Medical and Atmospheric Electricity — Postscript to Mr. 
Clarke's cases . . , . . <► . . . 363 

LECTURE XXXIV. 

Sleeplessness. — Sleeplessness from anxiety, grief, &c. — Case of jaundice accompanied by 
sleeplessness ; treatment — Remarks on purgative mixtures — On the proper time for adminis- 
tering opiates — Sleeplessness in delirium tremens — Chronic variety of delirium tremens ; 
treatment — Sleeplessness in fever ; case — Use of opiate injections — Delirium traumaticum — 
Constitutional irritation from blisters ; treatment — Sleeplessness in hypochondriacs and hys- 
terical females — On the use and abuse of cold applications to the head — Nervous symptoms 
in jaundice, &c. ......... 383 

LECTURE XXXV. 

On Inflammation and the motor powers which regulate the circulation . . . 399 

LECTURE XXXVI. 

Scarlet Fever — Description of the late epidemics of Scarlatina — Mr. O'Ferrall's communica- 
tion — Communications from provincial practitioners — Identity of Scarlatina and the epide- 
mics described by Fothergill, Huxham, and others — Professor Porter's case — Dr. Osbrey's 
account of the Scarlatina observed at St. Mary's Dispensary . . . .421 

LECTURE XXXVII. 

Influenza — Dr. Green's communications on the subject . . . .462 

LECTURE XXXVIIL 

Connection between diseases of different organs ; between arthritis, jaundice, and urticaria 
between periostitis produced by abuse of mercury, and hypertrophy of the liver — Details of 
cases illustrating this connection — Its explanation— -Hypertrophy of the liver produced by 
scrofula — Enlargement and inflammation of the liver after scarlatina — Importance of recog- 
nising this disease — Connection between disease of the live? and disease of the heart — • 
Chronic hepatitis from this source, curable in young persons — Enlargement of the spleen 
connected with superficial ulceration of the legs — Erysipelas and gangrene, sometimes of a 
pseudo-inflammatory character — Treatment of this form of the disease . . 480 

LECTURE XXXIX. 

Gout. — On constitutional inflammation in general — on fugitive swellings and pains — Curious 
case of erratic gout causing transient swellings — Gout affecting the lobe of the ear — Fatty hy- 
pertrophy of the ears — Gouty grinding of the teeth — Gouty neuralgia of the skin — Remarks 
connected with Dr. Kingston's researches on consumption — On paralysis in general — On 
paralysis depending on affections spreading from the extremities of the nervous system to its 
centre — Gouty ramollissement of the spinal marrow, two remarkable cases of — History of this 
hitherto undescribed form of the disease — Gout may affect the spinal marrow — Combination 
of arthritic inflammation with bronchitis — Effects of various remedies, particularly mercury 
— Effects of this in chronic bronchitis — Dr. O'Beirnes's plan of rapid mercurializalion in 
certain affections of the joints — Application of the same method to inflammation of the lungs 
of a scrofulous character — Cases in illustration ..... 493 

LECTURE XL. 

Periostitis — Pleuro-Pneumonia — Abscess of the heart — Chronic Laryngitis — Prurigo, cases 
simulating tic douloureux — Jaundice with arthritis and urticaria — Urticaria . . 529 



CONTENTS. 15 

LECTURE XLI. 

Case of secondary symptoms which made their appearance soon after a mercurial course ; 
method of treatment — Case of syphilitic eruption — Mouth suddenly affected by a small 
quantity of mercury — Effects of this on the progress of the cure — Earache preceded by rigorg 
coming on during the course of fever; danger of; treatment — External tenderness; value 
of, as a symptom in inflammation of brain, lungs, abdomen, &c, &.c. — Vomitin? considered 
as a symptom in fever; its treatment — Chronic rheumatism ; successful treatment of — Ob- 
stinate case of arthritis ; cure of, by local applications — Observations on the effects of mer- 
cury applied locally — Case of syphilitic iritis ; action of belladonna in . . 556 

LECTURE XLII. 

Persesquinitrate of iron in chronic diarrhoea — Newly observed affection of the thyroid gland in 
females — Its connection with palpitation ; with fits of hysteria — Erysipelas — Remarks on 
the formation of acidity of the stomach in indigestion — Psoriasis — Treatment by arsenic 569 

LECTURE XLIII. 

Pleuro-pneumonia — Cases of latent pleurisy ; of pneumonia — Phthisis ; latent ulceration of 
the bowels in — Diarrhoea of phthisis — Observations on the stammering of paralytic persons 
— Its explanation — Very remarkable case of stuttering cured by chronic laryngitis — Treat- 
ment of hoarseness — Velpeau's method of treating sore throat . . . 577 

LECTURE XLIV. 

Amaurosis. — Acetate of lead in Asiatic cholera — Remarkable mobility of sternum . 585 

LECTURE XLV. 

Case of phlebitis — Remarks on the symptoms and treatment of this disease — Pathology of 
phlegmasia dolens — Its treatment — Case of cancrum oris — Fatal termination — Remedies 
employed — Case of ague-cake — Observations on the different varieties of ague — True ague, 
or intermitting fever — Ague produced by inflammation of internal organs — Nervous ague — 
Hysterical ague — Treatment of ague-cake ...... 594 

LECTURE XLVI. 

Glanders and button-farcy in the human subject — Particulars of a case of glanders, with the 
post-mortem appearances — Remarks on the variety of skin diseases produced by the intro- 
duction of an animal poison into the system — Case of button-farcy — Analogous appearances, 
where, as in typhus, an animal poison is sometimes generated in the body — Furuncular 
inflammation, or carbuncle, generated by animal poison ; also tubercles — Sometimes a pre- 
ternatural whiteness precedes the purple hue of mortification — Remarks on phlegmasia 
dolens — Phlegmasia dolens of the eye ...... 606 



CONTENTS OF DR. GERHARD'S LECTURES. 

LECTURE I. 

Acute articular rheumatism — Connection with inflammation of the cardiac membranes- 
Treatment, bleeding, opiates, &c. . ...... 627 

LECTURE II. 

Continuation of acute rheumatism — Rubeola, or measles, in adults and children — Symptoms 
— Complications — Treatment ....... 634 

LECTURE III. 

Inflammations of serous membranes — Pathological anatomy — General symptoms — Pleurisy — 
Tuberculous peritonitis, &c. . . . . . . . .641 

LECTURE IV. 

Acute inflammations of the membranes of the heart — Pericarditis — Endocarditis . 649 

LECTURE V. 

Tubercular meningitis — Case — Anatomical characters — Symptoms • . 656 



16 CONTENTS. 

LECTURE VI. 

Peritonitis from cancer of liver — Acute Meningitis — Diagnosis — Symptoms — Treatment 664 

LECTURE VII. 

Chronic meningitis — Apoplexy— Paralysis of the insane .... 672 

LECTURE VIII. 

Apoplexy and inflammation of the brain (continued) — Functional diseases of the brain 679 

LECTURE IX. 

Delirium tremens — Symptoms—Stages — Varieties — Complications — Treatment ' . 685 

LECTURE X. 

Dysentery — Varieties — Diagnosis — Anatomical lesions — Treatment . . . 695 

LECTURE XL 

Subacute dysentery (continued) — Pathology and treatment — Phthisis pulmonalis . 701 

LECTURE XII. 

Phthisis pulmonalis— Pathological characters of gangrene of the lungs , . . 716 

LECTURE XIII. 

Phthisis pulmonalis (concluded) — Cases — Treatment . . . . 720 

LECTURE XIV. 

Pneumonia — Jaundice — Tubercular meningitis — Pathology of laryngitis and laryngeal 
phthisis . . . . . . . . . . 723 

LECTURE XV. 

Typhus and typhoid fever — Symptoms — Treatment ..... 730 
Notes on typhus and typhoid fever in the year 1848 ..... 736 



ON CLINICAL INSTRUCTION, 



INTRODUCTORY LECTURE. 

Gentlemen, — Before we commence an examination of the cases at 
present in the medical wards of this hospital, it is necessary to explain 
the method of instruction which I mean to adopt. Employed elsewhere 
in learning the principles that constitute the basis of medical education, 
you ought to be impressed with a precise notion of the peculiar objects 
and utility of hospital attendance. You come here to convert theoretical 
into practical knowledge; to observe the symptoms of diseases previously 
known to you only through the medium of books or lectures ; to learn 
the art of recognising these symptoms, and of appreciating their relative 
importance and value ; to study their connexion with morbid alterations 
of internal organs ; and, finally, to become acquainted with the best 
method of relieving your patients, by the application of appropriate 
remedies. 

Such, gentlemen, are the objects you seek in coming here; and in 
proportion to the number and importance of these objects, are the degree 
of responsibility attached to your clinical instructors, and of blame to 
yourselves, should the opportunities which this institution offers for your 
benefit be neglected. 

The other branches of medical education may be cultivated at different 
times, and according to a certain order of succession — one period of 
your studies demanding a particular application to anatomy, another to 
chemistry, while a third must be especially devoted to materia medica. 
With the observation of disease it is otherwise. From the very com- 
mencement, the student ought to witness the progress and effects of sick- 
ness, and ought to persevere in the daily observation of disease during 
the whole period of his studies. 

The human mind is so constituted, that in practical knowledge its 
improvement must be gradual. Some become masters of mathematics, 
and of other abstract sciences with such facility, that in one year they 
outstrip those who have laboured during many. It is so, likewise, in the 
theoretical parts of medicine ; but the very notion of practical knowledge 
implies observation of nature; nature requires time for her operations; 
and he who wishes to observe their development will in vain endeavour 
to substitute genius or industry for time. Remember, therefore, that 
however else you may be occupied — whatever studies may claim the 
remainder of your time, a certain portion of each day should be devoted 
to attendance at a hospital, where the pupil has the advantage of re- 
ceiving instruction from some experienced practitioner. A well-arranged, 
and sufficiently extensive hospital, contains every thing that can be 
desired by the student ; but, unfortunately, his improvement is seldom 
3 



18 ON CLINICAL INSTRUCTION. 

proportioned to the opportunities he enjoys. Whence this deficiency ? 
How does it happen that many attend hospitals day after day, and year 
after year, without acquiring much practical knowledge ? This may be 
attributed to want of ability or diligence on the part of the student, or to 
an injudicious or careless method of teaching on the part of the hospital 
physician. It may be well to examine more in detail the errors to which 
the student and the teacher are respectively most exposed. 

A great number of students seem little, if at all, impressed with the 
difficulty of becoming good practitioners ; and not a few appear to be 
totally destitute of any prospective anticipation of the heavy, the awful 
responsibility they must incur, when, embarking in practice, the lives of 
their fellow-creatures are committed to their charge. It is by persons of 
this description that the earnest attention, and permanent decorum, which 
ought to pervade a class employed in visiting the sick, are so frequently 
interrupted. Young men of the character to which I allude, attend, or as 
it is quaintly enough termed, walk the hospitals very regularly, but they 
make their appearance among us rather as critics than as learners ; they 
come, not to listen but to speak ; they consider the hospital a place of 
amusement rather than of instruction. I am happy to be able to state that 
such characters are not very numerous here, for this hospital possesses no 
other attractions, confers no special qualification beyond the knowledge 
which may be obtained within its walls.* 

Of those who are anxious to learn their profession, a great number fail, 
and are found wanting when their studies are finished ; in a few, the 
failure may be traced to a deficiency of intellectual powers ; but in the 
majority it is owing to their studies being erroneously directed. Thus I 
have known many who have displayed a taste for the study of the pro- 
gress and treatment of acute diseases, while they paid but little attention 
to complaints of a chronic nature. This predilection is not confined to 
students ; professors and authors in general seem to participate in this 
taste ; and, consequently, we find that acute diseases form the favourite 
subjects of clinical lectures, and occupy the greatest, portion of medical 
literature, — and that for obvious reasons ; for if the course of acute dis- 
eases, such as fever and the phlegmasia?, be compared with that of 
chronic maladies, we shall find that the former begin, continue, and end 
in a manner comparatively so regular and definite, that their progress can 
often be accurately predicted, and their terminations foreseen — a circum- 
stance which enables us not only to predict the event with confidence, 
but obtain, by the well-timed application of active remedies, relief, evi- 
dently the result of the means employed, and, consequently, reflecting 
credit both upon.the physician and the art of medicine. How satisfactory 
are our feelings on arresting the progress of pneumonia by venesection, 
or tranquilizing the mania of delirium tremens by means of opium ! Far 
different is the case with chronic diseases ; in their commencement gene- 
rally obscure, insidious, and irregular ; in their terminations necessarily 

* Since this was written, the Meath Hospital became for several years a privileged hospital. 
Latterly this premium upon idleness has been again withdrawn from us, and I most heartily 
rejoice that this and other hospitals have ceased to form a sort of favoured oligarchy to the 
exclusion of the less extensive institutions of this city J every thing like monopoly tends to 
retard the advancement of science, and I see no reason why a hospital with 50 beds should 
be inferior to one with 100. It is not the quantity of disease a teacher treats which renders 
his lessons instructive ; his diligence and accuracy of observation are the best means of 
instructing the pupils. 



INTRODUCTORY LECTURE. 19 

uncertain ; frequently transferring themselves, as it were, from one part 
of the system to another, occasioning unexpected and anomalous symp- 
toms, and involving in their destructive course almost every tissue of the 
body. From the very length of their duration, they are also more liable 
to be modified by new physical and moral influences, affecting either the 
mind or body ; and are, in a word, more closely leagued with time, the 
parent of mortality. In the treatment of such affections, the greatest 
judgment and patience are requisite ; there is here no room for the appli- 
cation of heroic remedies ; nor can the physician expect, from his most 
persevering exertions, that speedy benefit by which he acquires eclat in 
acute cases, for it must be remembered that chronic diseases require 
chronic remedies. 

This most difficult department of medicine surely claims not the least 
portion of your attention, and you will attach more importance to this 
subject on considering that a knowledge of chronic diseases is essential 
to the surgeon, inasmuch as those who labour under them remain ex- 
posed to accidents which constitute his peculiar province.* 

Many students fail from another cause : instead of studying the most 
common, and on that account, the most important diseases, they acquire 
a taste for observing and relating singular and rare cases, as if their chief 
object was to obtain a store of curious medical information. Let me 
warn you against this amusing, but comparatively unprofitable employ- 
ment of your time. Suffer not yourselves to be misled by those who 
prefer the gratification of an idle curiosity to the laborious investigation 
of ordinary diseases. 

Students should aim not at seeing many diseases every day, not at 
visiting daily numerous cases ; no, their object should be constantly to 
study a few cases with diligence and attention ; they should anxiously 
cultivate the habit of making accurate observations. This cannot be 
done at once ; this habit can be only gradually acquired. It is never the 
result of ability alone ; it never fails to reward the labours of patient 
industry. You should also endeavour to render your observations not 
only accurate but complete ; you should follow, when it is possible, every 
case from its commencement to its termination ; for the latter often affords 
the best explanation of previous symptoms, and the best commentary on 
the treatment. Did time permit, I could expose many other erroneous 
practices calculated to render your studies comparatively unprofitable ; 
but I must turn from the student to the teacher — from the errors of the 
learner to the imperfection of the mode adopted for instructing him. 

I have had an opportunity of observing with attention three different 
methods of conducting clinical instruction ; the first is that practised in 
Edinburgh and Dublin. I shall select that of Edinburgh for examination, 
being by far the most celebrated of the British schools of physic, and 
much resorted to even by foreigners for instruction.! Two clinical 
clerks, one for the male, another for the female wards, are selected by 
the physician from among the senior pupils ; their business is to write an 
accurate history of the cases, to report the effects of medicines, and record 
the symptoms which may have occurred since the physician's last visit. 
All this is generally done with fidelity and zeal. At his daily visit the 

* At the time this lecture was written, the absurd idea that the education of a surgeon 
should differ from that of a physician, had not been altogether abandoned, 
f I speak of Edinburgh as it was when I studied there in 1819. 



20 ON CLINICAL INSTRUCTION. 

physician stops at the bed of each patient, and having received the neces- 
sary information from his clerk, he examines the patient, interrogating 
him in a loud voice, while the clerk repeats the patient's answer in a 
tone of voice equally loud. This is done to enable the whole audience 
to understand what is going on ; but, indeed, when the crowd of students 
is considerable, it is no easy task ; it requires an exertion almost stento- 
rian to render this conversation between the physician and his patient 
audible by the more distant members of the class ; while the impossibility 
of seeing the patient, obliges all who are not in his immediate vicinity to 
trust solely to their ears for information.* This information is not indeed 
neglected, for every w T ord so attentively listened to, and heard with so 
much difficulty, is forthwith registered most faithfully in each student's 
case-book ; and afterwards all the observations the professors make in 
their clinical lectures are taken down with equal care and fidelity. It is 
really a pity to find so much labour and diligence thrown away ; for it is 
evident that the practice of medicine cannot be thus taught or learned, 
as it were by hearsay ; and it is consequently to be feared, that many are 
annually dubbed Doctors at Edinburgh, who have been scarcely ever 
called on to write a prescription. The chief objection to this mode of 
teaching is, that however w r ell inclined the student may be, he is never 
obliged to exercise his own judgment in distinguishing diseases, and has 
no opportunity of trying his skill in their cure ; and, consequently, at the 
end of his studies he is perhaps well grounded in the accessory sciences 
— is a perfect medical logician — able to arrange the names of diseases in 
their classes, orders, and different subdivisions ; he may be master of the 
most difficult theories of modern physiologists ; he may have heard, seen, 
and if a member of the Medical Society, he may have also talked a great 
deal ; but at the end of all this preparation, what is he w T hen he becomes 
a full Doctor? — a practitioner who has never practised ! 

I do not assert that a diligent student may not obtain a good deal of 
knowledge by attending one or several clinical courses in Edinburgh ; no 
doubt he will gain many useful general ideas concerning the nature and 
treatment of disease ; and if he himself examines the patient after the 
physician's visit, he may even acquire a certain degree of tact in recog- 
nising symptoms and appreciating their value. This method of instruc- 
tion is, indeed, very useful, and nothing better can be devised for a 
beginner ; but for the more advanced student it is by no means sufficient, 
nor is it calculated to give him practical experience, without which all 
other acquirements are of no avail. I say it does not give him expe- 
rience, because he has at no time been charged with the responsibility of 
investigating a case for himself, and by himself — because at no time has 
he been called on to make a diagnosis unassisted by others^ — and above 
all, because he has never been obliged to act upon that diagnosis, and 
prescribe the method of treatment. If those who have been thus edu- 
cated, and who have been made doctors upon so slender a foundation, 
were to confess the truth, we should be presented with a picture calcu- 
lated to excite dismay, if not a stronger feeling. How many doubts and 
distracting anxieties attend such a man at his first patient's bedside ? If 

* When this information was conveyed, as it formerly was at Sir P. Dun's Hospital, in 
Latin, the student had to encounter another barrier to the acquisition of knowledge. I have 
called the language Latin, in compliance with the generally received opinion concerning its 
nature. 



INTRODUCTORY LECTURE. 21 

the disease be acute, and life in imminent danger, if he shrinks under 
this sudden and unusual load of responsibility, he gains little credit for 
professional ability ; if, on the contrary, inexperienced as he is, he 
assumes that decision of judgment, that energy of practice, which expe- 
rience alone can confer, it is not improbable that the result may be still 
more disastrous. 

Gentlemen, I am not drawing a picture from my imagination alone ; I 
have had occasion too often to shudder at the original — too often to 
deplore the sad effects resulting from the well-meant but totally mistaken 
treatment employed by young men ; and often have I regretted that, 
under the present system, experience is only to be acquired at a con- 
siderable expense of human life. There is, indeed, no concealing the 
truth, the melancholy truth, that numbers of lives are annually lost in 
consequence of mal-treatment. The victims selected for this sacrifice, at 
the shrine of experience, generally belong to the poorer classes of society, 
and their immolation is never long delayed when a successful candidate 
for a dispensary commences the discharge of his duty. The rich, how- 
ever, do not always escape ; nor is the possession of wealth in every 
instance a safeguard against the blunders of inexperience. This charge 
of inexperience is not necessarily confined to the beginner ; it applies 
equally to many an old practitioner, whose errors have grown, and have 
increased in strength, during a long succession of years ; because, from 
a defect in his original education — from the absence of a properly directed 
clinical instruction, he commenced practice without having previously 
acquired the power or the habit of accurate observation ; because he had 
not in his youth been taught to reason justly upon the facts presented to 
his view ; because, not having learned in the beginning to think accu- 
rately, he contracted a loose and careless mode of examining the progress 
of disease, and the effects of remedies; and, consequently, the lapse of 
time has had no other effect upon his errors, than that of rendering them 
more inveterate. Such a man has generally an overweening confidence 
in his own judgment ; he never detects or is conscious of his own mis- 
takes ; and instead of improvement, years bring only an increased attach- 
ment to his opinions — a deeper blindness in examining the results of his 
own practice ; and do not such persons abound in every branch of the 
profession ? — are there not general practitioners, are there not physicians, 
are there not surgeons, are there not apothecaries, who answer to this 
description, and who nevertheless are cheerful in their demeanour, and 
enjoy a good repute among their clients? Believe me, gentlemen, the 
quacks who cover our walls with their advertisements, vend not annually 
to the community more poison than is distributed according to the pre- 
scriptions of your routine and licensed practitioners ; and yet the science 
of medicine is improving daily, and treatises on the practice of physic 
are every day multiplying. Why, then, is society so infested ? Many 
circumstances concur to produce this effect; but the most influential is 
undoubtedly that which now occupies our attention : I mean a system of 
clinical instruction radically wrong, because it does not teach the actual 
practice of medicine. Is there any other profession or art, or even trade, 
in which any but a madman would embark unprovided with a store of 
practical knowledge ? But enough of this unpleasing subject. Let us 
next consider what systems have been adopted in other countries, with a 



22 ON CLINICAL INSTRUCTION. 

view of judging how far it is either practicable or expedient to introduce 
them into this.* 

In France, the mode of conducting clinical instruction is very similar 
to that which we have already described, and consequently it is attended 
with nearly the same advantages and defects. In the French hospitals, 
however, no reports are dictated to the clerks, and more care is taken to 
explain the symptoms and progress of each case at the bedside of the 
patient ; in fact, these explanations answering to the original institution 
and design of clinical lectures, are attended with many important advan- 
tages, and are well worthy of imitation. By this means the trouble and 
uncertainty of a circumstantial and detailed description are frequently 
avoided by a direct reference to the matter to be described ; and the 
interest of the student is secured by a very slight exertion on the part of 
his instructor, w r hile the latter owes many new ideas to the degree of 
attention which he is thus forced to give each case. It is true that the 
duration of the visit is thereby increased ; and in Italy, where the same 
plan is pursued, it is not unusual for Tommasini to expend, in the 
morning, more than two hours upon eight or ten cases, besides the time 
devoted in the evening to the same purpose. Where the importance of 
the subject to be taught is so great, it is wisely judged that the teachers 
must be laborious ; and it is thought necessary to use every possible 
means to convey clear ideas concerning each case to the student. His 
attention is not distracted by seeing a great number of cases in rapid suc- 
cession, nor (as is too often the case in the hospitals of Dublin and Lon- 
don) are the inquiries dictated by a laudable curiosity on the part of the 
student, suppressed by a forbidding demeanour or an uncourteous answer 
from his teacher.f Although the French clinic thus presents several 
manifest superiorities over the British, yet it is liable to the chief objec- 
tion already urged against the latter — that the student is not supplied 
with an opportunity of learning the actual practice of his profession. I 
am by no means disposed to join in the cant of humanity ; yet I cannot 
overlook another disadvantage to this mode of teaching. I cannot help 
feeling that it is scarcely justifiable to lecture upon a patient's case in his 
presence, and in his native language ; that it is cruel to explain, (as must, 
when this method is adopted, be often done) that the patient is labouring 
under a fatal complaint. During such a lecture, I have often watched 
the worn and pallid countenance of the sufferer, while he listened atten- 
tively to the record of his past and present sufferings, and I have marked 
the settled expression of despair it assumed when the prognosis thus 
tediously ushered in was too clearly announced. It is cruel to banish 

* As truth has obliged me to expose a fault, which the Edinburgh school shares in common 
with the other schools of Great Britain, I am bound in candour to acknowledge the very great 
advantages which Edinburgh, in other respects, offers to students ; they there find themselves 
surrounded by so much diligence, enthusiasm, and zeal, that they can scarcely resist the im- 
pulse of improvement, and consequently many learn there to think and to labour, who had 
been previously careless idlers. "Were it possible to learn practical anatomy in Edinburgh. 
and were the mode of conducting clinical instruction improved, what might not be effected in 
a university otherwise so eminent 1 

-[• In this respect our hospital physicians and surgeons have improved much since 1821. I 
am strongly disposed to believe that the improvement was not owing to a voluntary change, 
but to a certain salutary fear of public castigation from the weekly medical press ; much, how- 
ever, remains to be done, for the influence of the last century has not yet entirely ceased, and 
there are those still lingering among us, who no doubt regret the aristocratic era, when an 
impassable gulf lay between the student and his teacher. 



INTRODUCTORY LECTURE. 23 

from the sick man's bed his sole remaining comfort — it is unmerciful to 
scare away hope, his only consolation during hours of pain and watching. 
We ought never to allow any expression to escape from us which could 
possibly add the terrors of apprehension to the weight of actual suffering. 
On this account, while we borrow the useful part of their system from the 
French, we must correct so glaring a defect by making use of the Latin 
language, whenever it is absolutely necessary to make any observation 
that might alarm the patient.* One of the most important duties of a 
surgeon, or physician, consists in the practice of humanity ; and it is 
very doubtful whether the student does not experience as much difficulty 
in deriving benefit, not so much from the precept as the example of his 
seniors, in this department of his profession as in any other. Observe, 
gentlemen, I speak not of French, but of Irish hospitals ; for, with the 
exception of the objection already adverted to, the conduct of the French 
medical men is in every respect praiseworthy. We do not find them 
indulging in coarse, harsh, and even vulgar expressions to their hospital 
patients ; we do not find them provided with two vocabularies — one for 
the rich, and another for the poor.f The medical, more than any other 
profession, requires that the better feelings of our nature should be culti- 
vated and fostered. The nature of anatomical pursuits obliges us to 
violate many of our natural prejudices, and disregard some of our strongest 
propensities ; let us therefore be doubly anxious to give, by means of the 
most diligent cultivation, an additional and more vigorous growth to our 
better feelings — to our social affections ; — and if we are accused of dis- 
respect for the dead, let us answer the accusation by our humanity to the 
living. 

But to return to our subject. The third mode of conducting clinical 
instruction, is that adopted generally throughout Germany ; and which, 
in addition to the means of improvement, comprehended in the plan of 
the French and English methods, possesses the advantage of allowing 
the more advanced students to undertake the care of patients in the hos- 
pital, under the direction of the attending physician. 

The importance of clinical instruction is so much felt in Germany, that 
each school has three distinct medical clinics attached to it, by which 
means the labour of teaching is divided among the professors, and the 
number of students attending each is diminished. There is one clinical 
hospital for the treatment of acute diseases, and another for chronic dis- 
eases, while a clinical dispensary is devoted to the care of extern patients. 
The pupils are divided into two classes — the more advanced, who get 
the care of patients, and the junior students, who merely look on and 
listen. When a patient is admitted, his case is assigned to one of the 
practising pupils, who, when the physician is visiting the ward, reads 

* This rule is always observed in Germany, a country remarkable for the zeal and humanity 
of the medical profession. In Italy both professors and students are less scrupulous. Thus, 
Dr. Clark relates that he has heard the case of a phthisical person explained, in all its bear- 
ings, by the professor at Uologna, in the patient's presence : in another instance, which 
occurred at the same place, a female, labouring under cancer uteri, burst into tears on hearing 
a detailed account of the nature of her complaint ! 

-f- When the above lecture was delivered, the abuse I speak of was but too frequent ; and 
will it be credited that many other and greater abuses had existed during the preceding gene- 
ration ? Death, the most efficient of all reformers, had then removed several of the chief 
actors from the scene, for which, as on most other occasions, he has, I rather think, been 
undeservedly censured- 



24 ON CLINICAL INSTRUCTION. 

out the notes he has taken of the patient's disease, including its origin,' 
progress, and present state. This is done at the bedside of the patient ; 
and before he leaves the ward, the physician satisfies himself whether all 
the necessary particulars have been accurately reported by the pupil. 
After all the patients have thus been accurately examined, the professor 
and his class proceed to the lecture-room, and a list of the patients and 
the practising pupils is handed to the professor; the cases admitted that 
day are first inquired into, and the pupils are examined concerning the 
nature of their diseases, their probable termination, and the most appro- 
priate method of treatment, — each student answering only concerning the 
patients intrusted to his special care. During this examination, the 
pupil's diagnosis and proposed remedies are submitted to the considera- 
tion of the professor, who corrects whatever appears to be erroneous in 
either, and then the student retires to write his prescriptions, while the 
rest of the cases and pupils undergo a similar examination. At the con- 
clusion, the prescriptions written by the students are read out in order 
by the professor, who strictly comments on and corrects any inaccuracy 
or inelegance they may contain. When the prescriptions have been 
revised and corrected, they are signed by the physician,' and handed to 
the apothecary to be made up and distributed. In some clinics, the price 
of each medicine is affixed to the bottle or box containing it, in order 
that the students may become acquainted with the comparative expense 
of various prescriptions, and may thus be enabled, in private practice, to 
accommodate, as far as is possible, the expense of the remedies to the 
circumstances of their patients. The clinic for extern patients is con- 
ducted on the same principles : patients who are able to attend, are exa- 
mined at the dispensary ; those who cannot leave their homes are visited 
by the senior practising students, who always seek the advice of the pro- 
fessor when the case is urgent, or the treatment doubtful. Nothing, gen- 
tlemen, can be better adapted than this plan of clinical instruction for the 
improvement either of the beginner, or of the more advanced student : 
this daily deliberation and anxious discussion concerning the nature and 
treatment of each case, is peculiarly interesting, and serves to accustom 
the beginner to habits of accurate examination, whereby he is taught to 
interrogate nature for himself, and learns the history and treatment of dis- 
ease, not from books and descriptions, but from direct observation. The 
advantages gained by the practising pupils are too obvious to require 
comment : being obliged to give reasons for every plan of cure that they 
propose, they are accustomed to a rational and careful investigation of 
disease, and enjoying the most important of all advantages — the early 
correction of their errors — they commence private practice with a suffi- 
cient degree of experience to render them unlikely to commit any very 
serious mistakes. 

It is evident that, according to the German method, no regular clinical 
lectures are necessary, as the pupil becomes accurately acquainted with 
the physician's views of each case, and no step is taken in the treatment 
without the reasons for it being given. This is the best sort of clinical 
lecture ; the pupils have their doubts solved, and their erroneous views 
corrected, while the professor is enabled to mention, as the disease pro- 
ceeds, every thing which he thinks is illustrative of its nature. 

Note. — Eleven years experience enables me strongly to recommend 
the method of instruction pursued in Germany. Since my appointment 



INTRODUCTORY LECTURE. 25 

to the Meath Hospital, I have had extensive opportunities of observing 
its good effects. Not a session has elapsed without furnishing proofs in 
its favour. This system, however, at first met with much opposition, and 
its introduction was ridiculed in every possible manner ; even now it may 
be doubted whether its well-wishers are as numerous as might be ex- 
pected. It is still opposed by several narrow-minded persons, whose 
opinions have much weight with the pupils. 

I remember perfectly w T ell having only two practising pupils in one 
class, but I was not discouraged ; and although we have had many nu- 
merous classes in the Meath Hospital, I doubt if any of them contained 
more talent and worth than was shared between my two pupils, Dr. 
Townsend and Dr. Stokes. 

Since the latter, from being my pupil, has become my colleague, he 
has evinced the most indefatigable zeal in co-operating with me in 
instructing the pupils of the Meath Hospital ; and I am sure he joins me 
in testifying the constant gratification we have received from observing 
that our efforts have been so far successful, that no season elapses without 
bringing under our immediate observation several pupils whose diligence, 
zeal, and moral worth, insure our warmest approbation. Many of these 
gentlemen have already distinguished themselves, — and will always carry 
with them the best wishes of myself and my colleague. 

Postscript, 1842. — One-and-twenty years have elapsed since the pre- 
ceding lecture was delivered in the old Meath Hospital, and my subse- 
quent experience has amply verified the opinions therein expressed. I 
regret to say, that however influential these opinions may have proved in 
this city, their promulgation has produced but little benefit in causing any 
alteration in the mode of instruction pursued in the medical schools of 
the United Kingdom at large. So far, indeed, from the mode of con- 
ducting medical education being improved it has decidedly been altered 
for the worse. This assertion may appear paradoxical, nay almost incre- 
dible, when it is recollected how many new Universities and Schools 
have arisen since the year 1821 ; and how many novel medical profes- 
sorships have been founded. But if we carefully examine into the instruc- 
tions given, and the qualifications required in the first and most recently 
organised medical school of the day, viz., that of the London University, 
it would readily appear that a very small part of the student's time and 
attention is directed to acquire a knowledge of how disease is to be 
actually treated and cured — unless, indeed, we admit that a knowledge 
of Greek and Latin, of mathematics, algebra, and optics, of physics, 
botany, and chemistry, are necessary for this purpose. That this multi- 
plicity of subjects distracts every student is sufficiently evident a priori. 
And my own experience, from opportunities as a public teacher for many 
years, has satisfactorily convinced me that the practical parts of medicine 
are not taught so well now as formerly. It is not intended to assert that 
pupils now hear fewer clinical lectures or attend a shorter time in the 
Hospital, but it may be confidently affirmed that what they hear in these 
lectures, or see in the hospital, does not rivet attention or excite reflection 
now as formerly. For the pupil's avocations are so numerous that he is 
hurried from one to the other, and has no time to devote to serious reflec- 
tions upon what he has seen. In Edinburgh, the engrossing subject of 
conversation amongst students used to be the nature of the diseases of 



26 ON CLINICAL INSTRUCTION. 

the clinical patients, and the effects of remedies employed ; the clinical 
ward afforded constant themes for discussion, and its contents were con- 
stantly before the thoughts of the student. Such was Edinburgh in 1819, 
how it may be now in 1842, I cannot tell ; but be it changed for the 
worse, which I hope is not the case, it must result from a change in the 
system, and not a deterioration in the professors, whose unwearied dili- 
gence in the promotion of medical science daily brings forth fruits not 
unworthy of the best era of their predecessors. When so many seductive 
subjects are successively placed before the student, it cannot be expected 
that he will think almost exclusively on what is practical. On the con- 
trary the chances are that the chief energies of his mind will be misspent 
on the fascinating experiments and doctrines of chemistry, electricity, 
magnetism, and the polarization of light, to the exclusion of the less fas- 
cinating but all-necessary subject of disease and its treatment. In truth, 
the very rapid advances in the so-named collateral sciences has, of late 
years, seemed to render the practical improvement of the student less 
probable, and every day it becomes more unlikely that he will attain to 
the simple goal that he ought to hold in view, but will be diverted from 
the pursuit of the one indispensable object by the very means which he is 
taught to believe are necessary for its attainment. To this subject I shall 
recur in the following lecture, concluding this with an expression of satis- 
faction that since the first publication of my views upon medical educa- 
tion, they have been brought forward and enforced in several leading 
articles by the able Editor of the Medical Gazette ; and they have had, I 
have reason to hope, a favourable effect upon the manner in which medical 
education is conducted in my native city. 

This mode of instruction has been sanctioned by the respectable 
authority of my colleague, Dr. Stokes, and has also been much praised 
by Dr. Green, Professor of the Practice of Physic to the College of Phy- 
sicians, in his address at one of the opening meetings of the Medico- 
Chirurgical Society. 



INTRODUCTORY LECTURE. 

Session 1834-1835. 

Gentlemen, — As it is usual, at the commencement of a course of clinical 
instruction, to devote the first lecture to a consideration of some general 
topics connected with the line of studies most proper to be pursued by 
those who wish to attain eminence ; I have, in compliance with this cus- 
tom, thought it right to lay before you some observations on the proper 
mode of studying physiology and morbid anatomy, with a view of show- 
ing how best to derive advantages from these accessory but necessary 
sciences, sciences which, according to the manner in which they have 
been cultivated, have at different periods retarded, or advanced, that most 
important of all branches of professional knowledge, practical medicine. 
It is quite evident, that a knowledge of the functions and structure of the 
body in health is essential to him who undertakes the treatment of disease, 
and hence physiology has always occupied the attention of physicians. 
Physiology, however, may be studied in very different ways, and with 



INTRODUCTORY LECTURE. 27 

very different objects, and, until lately, all those who were engaged in 
the cultivation of this fascinating science, not contented with observing 
the state of the different parts and tissues during health, the nature and 
quality of the secretions, the mechanism and operation of the different 
organs, sought to ascend from a knowledge of effects to an investigation 
of causes, and after they had classified the more obvious phenomena of 
living bodies, endeavour to ascertain, if not the very principle of life, at 
least those motions and causes of motion which result immediately from 
the action of the living principle. Having thus, as they conceived, ob- 
tained a more accurate knowledge of the conditions of health, they pro- 
ceeded to form general explanations of the causes of disease, and frame 
general rules for their removal. This method, apparently so philosophical, 
and possessing so many attractions from the generality and simplicity of 
its application, has more than any other circumstance contributed to retard 
the progress of medicine. Gentlemen, this is not only an ancient, it is 
also a modern evil. We live among systems. It is true, that the prac- 
tice founded on the mechanical, mathematical, chemical and humoral 
physiologies, has been long since abandoned ; but the destructive system 
of Brown has not long quitted the stage, where its place is occupied on 
the Continent by those of Broussais and Rasori, and in Great Britain by 
the system which derives all diseases from derangement of the digestive 
function, or from inflammation. Physiology legitimately embraces not 
the study of vital actions, but merely aims at ascertaining and arranging 
their effects. The important facts, which its study discloses, are perhaps 
infinite in number. As long as we confine ourselves to these we advance 
at every step, and all is clear and intelligible ; but the moment we attempt 
to inquire into the causes and modes of vital action, we begin to retro- 
grade, and all becomes hypothesis and confusion. Thus, an examination 
of the organ of sight discovers a wonderful and beautiful optical arrange- 
ment, calculated to form on the retina a picture of external objects, exact 
both in its colouring and outline. The physiologist, examining with 
attention the different parts of the eye, and the laws of their respective 
refractions, investigates the means by which distinct vision is secured at 
different distances ; he compares the human eye and its appendages with 
that of animals which live in water, those which soar into the highest 
regions of the atmosphere, and those which burrow under ground. He 
considers the eye of the mole, feeble but protected against injuries likely 
to be encountered in carrying on its subterraneous works ; of the eagle, 
who, poised high in mid-air, selects its victim from the distant pasture ; 
of the fly, whose microscopic organ, with a range of vision scarcely ex- 
ceeding the limits of contact, distinguishes objects the most minute, and 
in all he finds variations in the optical instrument at once curious and 
intelligible. But when he endeavours to advance further in his inquiry, 
and tries to explain how an image painted on the retina, produces vision, 
whether by the means of undulations arising from the rays of light, and 
propagated along the optic nerve to the brain, or whether because the 
retina is a nervous expansion, highly organised and framed so as to feel 
the coloured image painted on it, he is at once arrested in his progress by 
the barrier which is every where interposed between physical and vital 
actions, between the mechanism of the organs of sense and the mode in 
which they produce ideas between body and mind. 

But has he, therefore, gained no real knowledge applicable to practical 



28 ON CLINICAL INSTRUCTION. 

purposes, or has his time been merely spent in a pleasing but useless 
study ? By no means ; — being acquainted with the meohanism and 
arrangement of the optical instrument, he is often enabled to remedy its 
accidental derangement. By means of a concave glass he corrects a too 
speedy, by a convex a too tardy, concentration of the rays of light. 
When the crystalline lens becomes opaque, his knowledge of its con- 
nexions, nature, and position, enables him either to remove it altogether, 
or to displace it from the axis of vision, or to promote its absorption, and, 
in order to effect the latter purpose, he mechanically irritates it, knowing 
by experience, that after such an irritation, the process of absorption com- 
mences, although he is quite ignorant of the connexion between mecha- 
nical irritation and this vital process. He who inquires into the physio- 
logy of the brain and spinal marrow can never discover the nature of 
nervous influence, or the manner in which pressure on these organs 
destroys, or irritation deranges, the motions of the voluntary muscles, and 
yet the entire treatment of cerebral or spinal diseases, whether sponta- 
neous, or from the effects of injury, is grounded on a knowledge of this 
physical fact ; without it we could not estimate the value or effects of 
morbid changes in the brain or spinal marrow. On this reposes the 
rationale of the treatment of all convulsive, paralytic, and apoplectic 
affections. 

Although we know not the manner in which the eighth pair of nerves 
superintends the respiratory process, although we understand not how 
the phrenic nerves influence the motion of the diaphragm, yet a know- 
ledge of these facts led to a relief of spasmodic asthma, and to the reco- 
very of persons apparently asphyxiated, by means of the Galvanic stimulus 
passed along the course of these nerves. Knowing that some of the 
nerves, distributed to the face, are destined for sensation, while others 
serve for muscular motion ; in cases of tic douloureux we divide the sen- 
tient and not the motive nerves. In these, and a thousand other instances, 
physical physiology supplies us with information at once interesting and 
practical ; it would be still easier to prove, as in the cases of Brown and 
Broussais, that vital physiology, by involving us in the discussion of sub- 
jects beyond the powers of our reason, never fails to entangle its votaries 
in a labyrinth, amidst whose mazes they move without progressing, and 
consume in idle speculations that time and labour they ought to spend in 
the acquisition of useful knowledge. But I trust the period has at length 
arrived when this error will be avoided ; for, on the whole, it must be 
confessed, that in consequence of a wrong method of studying, and a 
misconception of the true objects of physiology, this science has in many 
instances retarded the progress of practical medicine. 

Let us next consider the connexion of morbid anatomy with practical 
medicine. Many have mistaken the end and object of morbid anatomy, 
and there are not wanting some who even deny its utility, while others 
again, in their zeal for its improvement, have endeavoured to extend its 
limits so as to make it comprehend and embrace in the explanations it 
affords all the phenomena of disease. It is not easy to determine which 
of these parties has most injured the cause of practical medicine. Morbid 
anatomy comprehends not merely decided and permanent structural alter- 
ation, but embraces, so far as they are capable of being detected, even 
temporary physical changes in internal organs. In order justly to estimate 
its importance we should recollect that the first alteration in the texture 



INTRODUCTORY LECTURE. 29 

of a part is not the cause but the consequence of disease, for in every 
healthy organ the texture is natural, and as every change of texture is 
produced in consequence of derangement in the vital action of the vas- 
cular system of the part, it is obvious that structual alteration must in the 
first instance be always produced by functional derangement. Thus, the 
physical alterations which attend external inflammation, the tumefaction, 
the heat, the redness are not the causes but the consequences of diseases. 
But in thus reducing them to the rank of symptoms, do we diminish their 
importance ? Certainly not. For being immediately connected, as effects, 
with the primary cause, they prove the most useful of all symptoms, in 
enabling us to ascertain the seat and progress of diseased action. In this 
respect they possess a manifest advantage over the general or constitu- 
tional symptoms. Thus, in cases of spontaneous gangrene, phlegmonous 
inflammation, or erysipelas, what practitioner would be contented to draw 
his indications from the general symptoms, disregarding the appearance 
of the affected part? and yet this is exactly what those persons do who 
refuse the aid of morbid anatomy in the treatment of internal disease. 

In external diseases most of the physical changes in the affected part 
can be at once recognised ; their diagnosis is therefore comparatively 
easy, and their treatment w T ell established. In internal diseases the case 
is widely different, the physical alterations are here beyond the cogni- 
zance of our senses ; and, in order to ascertain their nature and situation, 
we must carefully compare the morbid appearances of internal organs, as 
revealed to us by dissection, with the symptoms during life. Although 
alteration of structure is in the first instance produced by a disease in the 
vital action of the part, yet this structural alteration may itself become a 
new cause of mischief. Thus the vascular system of the lungs, from 
some unknown cause, assumes such a change of action as produces a 
deposition into the pulmonary texture of various fluid and solid products, 
by which the entrance of the air into its vesicles is prevented, and the 
respiratory function, one of the most important of the body, is thus con- 
siderably deranged. Again, whatever be the original vital derangement 
which causes scirrhus of the pylorus, the obstruction thus formed is a 
secondary cause of new and important symptoms. Another consideration, 
which enhances the value of morbid anatomy, arises from the fact, that 
when diseased action fixes itself in any part of the body, whether external 
or internal, and there gives rise to physical alterations, experience teaches 
us, that the progress of the disease may be often arrested by removing its 
effects. Thus, to recur to the example of external inflammation, the 
redness, the swelling, the heat of the part are but symptoms, and yet we 
find great benefit from the applications of remedies capable of diminish- 
ing them ; hence we leech, and apply cold lotions, &c. From all these 
considerations it is evident, that whenever disease is attended with either 
a temporary or a permanent alteration in the tissue of an internal organ, 
it will be of the greatest practical importance to ascertain the nature and 
extent of that alteration, and the progress of practical medicine will be 
exactly proportioned to the accuracy with which this can be accom- 
plished. Thus, how much has the treatment of pectoral diseases been 
improved by the application of auscultation and percussion, means which 
are only useful by enabling us to ascertain the physical alterations induced 
by the disease, or, in other words, the morbid anatomy of the affectea 
organ. Without their aid, how trace the progress and follow the increase 



30 ON CLINICAL INSTRUCTION. 

or diminution of pulmonary inflammation ? — how demonstrate the exist- 
ence of dropsical or pleuritic effusion within the chest? — how detect 
latent pneumonia ? — how distinguish with certainty pleurodyne from 
pleurisy ? I could prove the utter impossibility of distinguishing many 
cases of bronchitic from tubercular phthisis without their assistance. I 
might refer to chronic emphysema of the pulmonary tissue, a disease of 
great importance, but actually unknown before the time of Laennec, who 
first accurately described it in the dead body ; indeed, before the appli- 
cation of percussion and auscultation, a perfect knowledge of this derange- 
ment of the pulmonary structure in the dead body would not have assisted 
our diagnosis, for how recognise it during life ? I might bring forward 
dilatation of the bronchial tubes, another disease wholly unknown before 
Laennec's time, and which, before his discovery, could not be recognised 
by the common method of observation. I might enlarge on the great 
utility of attending to the changes which take place within the chest in 
me'asles and scarlet fever, but the benefit resulting from an accurate 
acquaintance with the morbid anatomy of the thoracic cavity is now so 
generally acknowledged, that I shall rather choose my illustrations from 
other classes of diseases. , 

Nosologists, until very lately, were agreed in attributing considerable 
frequency to those cases of apoplexy and paralysis, which arise from 
serous effusion into the brain, or from a mere functional inaction or de- 
bility of the cerebral and nervous systems. This opinion was founded 
partly on speculative grounds, and partly on inadequate and imperfect 
post-mortem examinations, and in practical books the symptoms supposed 
to announce sanguineous, serous, and nervous apoplexy were dogmati- 
cally laid down. What was the consequence? — Most disastrous, as I 
have had occasion to witness, in some parts of the continent, where the 
elderly practitioners still adhered to the practice founded on this false 
pathology. What can be more melancholy than to see time wasted or 
misemployed in the exhibition of diuretics, given to promote absorption 
of serum effused into the brain, or of strong exciting remedies, such as 
arnica, camphor, &c, to overcome the nervous debility, in cases where 
copious depletion by the lancet and purgatives were urgently necessary. 
I do not deny that in some rare cases serous effusion into the brain is the 
cause of death from apoplexy. I have seen such an event supervene in 
chronic dropsy, but there the termination was very sudden, and the pre- 
vious history left no doubt as to the cause ; but in the majority of the 
cases formerly treated as serous or nervous apoplexy a more careful exa- 
mination would have detected marks of vascular excitement, or local 
inflammation, a subject I shall treat at large when on the pathology of the 
brain. A similar error in morbid anatomy led to a similarly erroneous 
practice in the treatment of hydrocephalus, and many cases of general 
and local dropsy. The effusion occupied the sole attention of patholo- 
gists ; the marks of preceding vascular excitement or inflammation 
escaped their notice. 

Time will not permit me to enlarge upon the light which morbid ana- 
tomy, rationally pursued, has shed upon diseases of the brain. It is suf- 
ficient to remark, that some of the most important modifications of inflam- 
mation in that organ have been only lately discovered, and it is only 
lately that a minute and extensive examination of the different changes 
the brain undergoes in disease, has begun to introduce a certain degree 



INTRODUCTORY LECTURE. 31 

of regularity and precision into a department where all before was con- 
fusion and inaccuracy. Examples of the utility of morbid anatomy might 
be brought forward without number : — the discovery of local inflammation 
being at times the cause of a disease in most of its symptoms resembling 
common ague ; the use of the lancet in the cold stage of ague, a practice 
which may be advantageously resorted to, in cases where each return of 
the fit is accompanied by a recurrence of inflammation in a vital organ, 
as the lungs or brain ; the connexion between inflammation of the mu- 
cous membrane of the stomach, and some of those symptoms of fever for- 
merly attributed to mere debility ; the influence of cerebral inflammation 
and congestion, in producing the symptoms formerly vaguely denominated 
typhus; the low character which fever assumes when accompanied by 
pneumonia (and that, too, often latent) ; the symptoms which are pro- 
duced by follicular ulceration of the intestines, which so frequently occurs 
in the course of fever ; the diagnosis between the pain produced by neu- 
ralgia of the abdominal nerves, and that resulting from structural diseases 
of the intestinal canal ; a more accurate knowledge of the state of the 
mucous membrane in the diarrhoea of phthisis, and in intestinal tympa- 
nitis : the numerous improvements in the treatment of diseases of the 
ear, which followed Itard's investigations concerning the morbid anatomy 
of that organ ; — these and many other discoveries, all replete with prac- 
tical advantages, are the results of the attention of our contemporaries to 
morbid anatomy ; and, were I to appeal to the records of surgery, I might 
bring forward examples, if not more important, perhaps more evident and 
striking, for the invention and success of most capital operations depend 
on a perfect knowledge of the structural derangements, the removal or 
cure of which is attempted. Of this, examples suggest themselves on 
every side, but none is more striking than the one devised by Dupuytren 
for the cure of artificial anus, the most disgusting and loathsome malady 
to which human nature is subject, and deemed altogether incurable, until 
that excellent surgeon, by a combination of profound pathological and 
physiological knowledge, succeeded in planning and executing an opera- 
tion, that were alone sufficient to immortalise his name. 

The study of morbid anatomy, however, is attended with no ordinary 
difficulties, and, when imperfectly understood, is liable to lead to erro- 
neous results, for it requires much candour, much patience, and that 
experience which can be only acquired by long-continued practice, to 
enable us to judge concerning diseased appearances. The power of 
accurately discriminating in the dead body the traces of disease cannot 
be suddenly acquired, and so numerous are the various errors to which 
superficial observers are liable, that much injury has thus resulted to 
medical science, diseased appearances being in some cases overlooked, 
and in others recorded where they did not exist. Those who are aware 
how often the congestion, which frequently takes place immediately 
before or after death, in the pulmonary tissue, and in the mucous mem- 
brane of the lungs and alimentary canal, alters the physical properties of 
these parts, so as almost exactly to simulate the vestiges of inflammation, 
will understand how it happens that in investigations connected with the 
real or supposed diseases of these parts, facts have been marshalled against 
facts, and observations arranged against observations, until the path which 
promised simplicity and order terminated in perplexity and confusion. 
Hence the doctrine of Broussais received so many corroborations, and 



32 ON CLINICAL INSTRUCTION. 

appeared to rest upon numerous series of undoubted and well-authenti- 
cated facts. 

The morbid anatomist must of all things beware of seeing too much. 
He must av r oid imposing on himself by every where seeing exactly what 
he expected to see, and above all things let him not always force himself 
to see something: for many diseases proceed to a fatal termination with- 
out having produced any evident morbid alteration. 

When I come to treat of the pathology of the brain and nervous sys- 
tem, I shall have occasion to advert to errors which late authors have 
committed from too great an anxiety on the one hand to reduce to a certain 
and definite system the morbid appearances of the brain and spinal mar- 
row, as connected with their diseases, and, on the other, to find, in every 
case where the cerebral or nervous functions had been diseased, lesions 
of structure to account for the symptoms. Thus, to cite one of numerous 
instances, I shall have occasion to prove that epilepsy and mania often 
commence suddenly and violently, without the existence of any organic 
alteration; and, indeed, that organic lesions are not necessarily connected 
with these formidable diseases is sufficiently proved by the occasional 
sudden manner in which they cease. Thus, a gentleman of great literary 
reputation was many years a patient of mine before his death, which 
happened in 1831, at the age of seventy. From the age of twenty-five 
to fifty-five he suffered from violent and frequently recurring fits of epi- 
lepsy ; after having continued thirty years the disease ceased suddenly, 
without any assignable cause, and for the last fifteen years of his life he 
had not a single fit. I shall have occasion to show you how fine-drawn 
and how ill-founded the observations of those who profess to account for 
every nervous disturbance during life by cerebral lesions, w T ho profess to 
distinguish accurately during life inflammation and irritation of the arach- 
noid or dura mater from irritation or inflammation of the brain itself, who 
maintain that one series of symptoms is produced by inflammation of the 
cortical, and another by inflammation of the medullary, substance, who 
have strained their eyes to discover, and their veracity to impose upon 
us, proofs that inflammatory or other diseased states of certain portions of 
the brain caused invariably similar affections of certain mental functions. 
These errors of some, even of the most eminent French pathologists, it 
will be my duty to notice from time to time ; but I am sorry to say that 
much more unpardonable errors and misstatements have found their way 
into English and Irish publications on the pathology of the brain, and 
which I shall be compelled to speak of hereafter. 

Having made the preceding observations on the dangers which arise 
from an ill-directed application of the studies of physiology and morbid 
anatomy to the practice of medicine and surgery, I feel myself impera- 
tively called on to present the other side of the question to your view, in 
exposing the still more dangerous doctrine advocated by those who de- 
preciate the value of pathology and morbid anatomy as only instructive 
after the death of the patient, and even then as not unfrequently calcu- 
lated rather to mislead than to advance the interests of practical 
medicine.* 

It must be conceded that he who is only a physiologist cannot hope to 

* The dangers above enumerated may be almost all avoided by institutions, such as the 
Dublin Pathological Society, founded in 1838, and by means of which morbid specimens are 
exposed to an examination most likely to disclose their real nature. 



INTRODUCTORY LECTURE. 33 

cure disease, and that the mere morbid anatomist will be often misled by 
post-mortem appearances, if he has not attentively watched the progress 
of symptoms and the effects of medicines during life, for, unless this be 
done, he will, as I have already said, often mistake secondary for primary 
lesions, will confound effects with their causes, and will refer to certain 
alterations of structure that which had originated in a functional disorder, 
a morbid state of parts very different from that which is observed after 
death. But when, to an accurate knowledge of physiology and morbid 
anatomy is joined an extensive observation of the progress of symptoms 
and the effects of therapeutical agents, how much more certain and satis- 
factory will be our practical decisions, and how much more likely our 
efforts to be attended with success, than if we merely studied disease at 
the bedside of the patient. In the latter case, we might indeed become 
expert nosologists, be accurately acquainted with certain groups of symp- 
toms, and even not unfrequently adopt the proper method of treatment. 
These symptoms, considered together, we would call by a certain name, 
and hand down to posterity this new acquisition of medical knowledge, 
perhaps clothed in the garb of a dead language, and invested with the 
false dignity of a learned tongue. But what have we really thus effected 
for posterity?. — Our followers read our definitions of disease with an 
acquiescing admiration, and, sure of the efficacy of the remedies we have 
recommended, they go forth with an overweening confidence in the quest 
of the group of symptoms we have described, and when they have met 
with them they look upon their task as already half accomplished, and 
promise a successful termination of the disease. " Tell me the name of 
the disease," was the motto of the nosologist, " and I will tell you the 
remedy , but, gentlemen, I will engage to tell you the names of a hun- 
dred diseases, without your being able to name the proper method of 
treatment. I tell you a man has dropsy, his limbs are anasarcous, 
water is accumulated in the peritoneal cavity, his urine is scanty, and his 
thirst increased. Will you, from this very excellent nosological defini- 
tion, venture to prescribe for this case of dropsy? For the sake of the 
suffering patient and your own conscience, prescribe not on such data. 
And yet I regret to be obliged to say, that such a method of proceeding 
is by no means rare, nay, it is even a matter of daily occurrence. But 
this case of dropsy will not yield. Some other boasted specific hydra- 
gogue or diuretic is had recourse to ; still the patient grows worse and 
worse, and finally dies, but his friends are not discontented with the me- 
dical attendant, who excuses himself by asserting that he has successively 
resorted to every remedy which has been recommended in dropsy ; and 
in truth if you look over the list of medicines exhibited in rapid succes- 
sion, you will probably find that his excuse is not unsupported by facts. 
But, gentlemen, these cases in which every thing has been tried, are 
exactly those in which nothing has been tried, in which medicine has 
followed medicine, and each symptom of disease has indiscriminately 
been the object of attack, until death approaches with accelerated steps, 
and charitably closes a scene distressing to humanity, and disgraceful to 
the cause — I was going to say — of science, but who will venture to give 
so ennobling a name to this pseudo-practical knowledge, this worse than 
absolute ignorance? 

Gentlemen, I am not combating phantoms ; I do not, Quixote-like, 
contend with imaginary giants ; no, gentlemen, what I have described 
4 



34 ON CLINICAL INSTRUCTION. 

exists, the picture I have drawn has many an original. But let us have 
done with this subject ; let us turn to the gratifying considerations of the 
progress which practical medicine is making under its parent science, — 
physiology and morbid anatomy. 

The reason of man is now more fully employed than at any former 
period, a vast store of mental power, a vast mass of mind is every where 
at work ; what formerly was vainly attempted by the labour of a few, is 
now easily accomplished by the exertions of the many. The empire of 
reason, extending from the old to the new world, from Europe to our 
Antipodes, has encircled the earth — the sun never sets upon her domi- 
nions, — individuals must rest, but the collective intelligence of the species 
never sleeps ; at the moment one nation, wearied by the toils of day, 
welcomes the shades of night, and lies down to seek repose, another 
rises to hail the light of morning, and, refreshed, speeds the noble work 
of science ! 

All inquiries commence, as it were, at the same point, as the labours of 
their predecessors are equally at the disposal of all, and consequently it 
is not surprising we should often find them arriving together at the same 
end: thence the number of simultaneous discoveries of the same fact now 
so common. It is not unusual to find the publications of France, Ger- 
many, Italy and England, announcing the same discovery, and each zeal- 
ously claiming for their respective countrymen an honour which belongs 
equally to all. I am sorry to say that, with some splendid exceptions, 
this interesting and innocent controversy has been carried on by other 
Countries, while Ireland has put in no claim for a share of the literary 
honours awarded to the elTorts of industry or genius. But, gentlemen, I 
hope that this state of inaction, this state of mental torpor, has ceased, 
and that the time has passed away when we could not point out among 
our brethren any who had advanced the boundaries of the medical 
sciences, and thus promoted the interests of humanity. 

Now we can enumerate many whose names form a catalogue the sub- 
ject of congratulation for the present, of happy augury for the future, for 
cold must be the breast of him who will not hail with joy every symptom 
of our country's literary regeneration, dead the feelings which are not 
elated at the boon conferred on our species by every advance made by 
those who devote themselves to the grand, the noble pursuit of relieving 
the suffering, of healing the diseased ; but time bids me stop, I sha! 
therefore, conclude by observing that the attention lately devoted to the 
distinctions between real and pseudo-morbid appearances, the diligent 
cultivation of morbid anatomy by men not the slaves of preconceived 
opinions, the abandonment of ail systems whose baseless fabric rests on 
the phantoms of vital physiology, the importance now justly attached to 
medical statistics, to the study of endemic and epidemic maladies, to the 
operation of morbid poisons ; these, and various other circumstances, 
give us reason to hope that the progress of the human mind in investi- 
gating the means of preventing and curing diseases, will not be less rapid 
than it has been in the other departments of knowledge ; and thus it will 
be proved that if man has passions which impel him to the destruction of 
man, if he be the only animal who, despising his natural weapons for 
attack or defence, has devised new means of destruction, he is also the 
only animal who has the desire or the power to relieve the sufferings of 
his fellow-creatures ; the only animal in whom the co-existence of reason 
and benevolence attests a moral as well as an intellectual superiority. 



INTRODUCTORY LECTURE. 35 



INTRODUCTORY LECTURE. 

Session 1837-38. 



To-day, gentlemen, we commence our labours for the winter session. I 
hope you will manifest a steady and sustained diligence in your hospital 
attendance, observe carefully the various forms of disease submitted to 
your inspection, and accurately note the symptoms, together with the 
effects of the remedial measures. As usual, I have allotted the cases at 
present under our management to the more advanced students ; it is their 
duty to take charge of each, and write on a folio sheet of paper (which is 
pinned to a large card suspended over the patient's bed) its previous his- 
tory and existing symptoms ; thus recording its progress and treatment 
from day to day. In a former lecture, published in the Medical Gazette, 
I endeavoured to explain the advantages of this system ; at present, 
therefore, without entering into its details, I shall content myself with 
remarking that we have had many years' experience of its beneficial 
effects in the Meath Hospital, where this, the German mode of clinical 
instruction, was introduced by myself in 1821 ; I must remind you, how- 
ever, that even its utility is necessarily proportioned to the diligence of 
the student. There is no system capable of communicating information 
to the indolent ; every man must depend chiefly on his own assiduity, 
and all the teacher can do is to facilitate the means of acquiring know- 
ledge, and afford an example of punctuality and attention. I would 
seriously recommend everyone who undertakes the management of cases, 
to set out with a fixed determination to persevere throughout the whole 
session. Few things give me more concern than to find young men, who 
have commenced with ardour, becoming by degrees less and less indus- 
trious, until their hospital attendance degenerates into an irksome task, 
imperfectly performed, and at last wholly negiected. One of the most 
valuable things which the student can acquire is, a habit of daily dili- 
gence. The knowledge requisite for the efficient discharge of our pro- 
fessional duties is not to be acquired by sudden starts of intense applica- 
tion, or by the overwrought strivings of desultory exertion ; it demands a 
daily and hourly attention, a steady, constant, and accurate course of 
observation, continued uninterruptedly for years. 

I think students are very much misled as to the best mode of becoming 
good practitioners. This is an age of ambitious acquirement, and pro- 
fessional men seem to be ashamed unless they have the character of uni- 
versal knowledge. Every body studies ever} thing, and the consequence 
is that few know any thing well. We live amidst the din of declamations 
in favour of general education ; and are every where assailed by the 
ceaseless competition of those who vend cheap knowledge in the form of 
penny periodicals, lectures innumerable, and hosts of rival encyclopaedias ; 
but ours is not an age of calm unpretending acquirement, and severe 
precise study, without which, the effort to become good physicians and 
surgeons must prove vain and fruitless. Can any thing be more embar- 
rassing than the multitudinous array of studies presented to the young 
student, who comes to London or Dublin with the view of educating 



36 ON CLINICAL INSTRUCTION. 

himself as a general practitioner ? So many departments of knowledge 
are spread before him, and so numerous are the exhortations to study 
each with particular care, that he feels at a loss where to begin. The 
merits, advantages, and necessity of his own branch are insisted on by the 
respective teachers, with all the force of impressive eloquence ; and after 
running the round of introductory lectures (an initiatory penance duly 
performed by all beginners), he returns in the evening to his home, puz- 
zled and dispirited. He finds that it will be necessary for him to become 
an excellent botanist, an able and scientific chemist, and a profound ana- 
tomist ; that he must have some knowledge of zoology, be well versed in 
comparative anatomy, know how to detect poisons with accuracy, and 
study the legislative enactments which bear on questions of medical juris- 
prudence. Physiology, materia medica, therapeutics, nosology, morbid 
anatomy, the principles and practice of surgery, medicine, and midwifery, 
claim, all and each, his especial attention; nay, many teachers insist upon 
the necessity of his becoming master of several languages — Greek, Latin, 
French, and German ; while others assure him that he never can prose- 
cute scientific medicine with success, unless he studies physics as well as 
physic ; some are there even who encourage him to cultivate mineralogy 
and geology, as if forsooth a knowledge of these sciences could teach the 
laws that regulate diseased action, or the indications which should govern 
the exhibition of remedies. In a lecture lately published by my friend 
Mr. Hayden, I find it remarked "that to keep pace with the modern race 
of intellect, we should get on a railroad of literature; mathematics, natural 
philosophy, the art of drawing, and above all, logic, will be indispensa- 
ble." Dr. Elliotson would no doubt add metaphysics, animal magnetism, 
and phrenology, sciences he has cultivated with success, and taught with 
perspicuity! Dr. Latham, who has had sufficient courage to put forth 
his opinions on this subject, has demonstrated, with much truth and force, 
the injustice and folly of attempting to impose so many burthens on the 
minds of students, and has shown clearly the bad consequences resulting 
from such a mode of proceeding. No profession requires a sounder pre- 
liminary education than ours, and in none ought education to be more 
studiously directed to promote the activity and development of the mental 
powers, especially those connected with the habit of observation as well 
as with the judgment and memory. The latter faculty should be culti- 
vated from the earliest period, and the boy should be taught the chief 
anatomical names, as those of the different parts of the muscular, nervous, 
and vascular systems, which names he will of course find no difficulty in 
retaining when a man, and it will then only be necessary to learn the 
qualities of the things to which they belong. If, in addition to this, boys 
were taught the scientific names of the chief articles of the materia medica, 
and the technical terms and classifications of botany and chemistry, much 
trouble would be saved then! in after life : and their memories, while in 
the state of greatest activity, would be much better employed than in 
attaining the rules and terms of syntax, prosody, mythology, and ancient 
geography. I would not recommend any one to commence the actual 
study of medicine and surgery until the age of nineteen. Before that 
period the mind is not sufficiently ripe for practical observation, nor suffi- 
ciently stored with that knowledge (only to be gained by the daily inter- 
course of life) which teaches us to estimate the effects of moral or physical 
causes on the human system, imparts to us the power of weighing con- 



INTRODUCTORY LECTURE. 37 

Aiding evidence, and detecting the too frequently incorrect and erroneous 
statements of our patients. A certain knowledge of the world is indis- 
pensable to the physician ; and it is only loss of time — yes, of precious 
time — to employ boys in trying to learn what can only be acquired by 
men. Those who attend hospitals at too early an age are very apt to 
acquire careless habits of observation ; all the interest which disease pre- 
sents, when observed for the first time by matured minds, is lost to them, 
and all the attraction of novelty has ceased long before they possess that 
tact and experience which enable the adult to understand the meaning of 
symptoms, the progress and phases of morbid phenomena, and the effects 
of therapeutic agents. 

It is then the duty of parents, guardians, teachers, and all who super- 
intend the education of youth, to see that those who are destined for the 
medical profession should have their minds prepared and strengthened 
by diligent cultivation during early youth, not only by the attainment of 
extra-professional knowledge suited to their means and opportunities, but 
also by instruction in those portions of anatomy, materia medica, botany, 
and chemistry, which may be readily comprehended at -that age. Espe- 
cial care should be taken to impart to them some knowledge of the phy- 
sical qualities of medicinal substances. All this being done, when the 
student, arrived at maturer years, comes to grapple with the practical 
departments of his profession, he will find many difficulties easily sur- 
mounted, and at this period he should disengage himself from too devoted 
an attention to the accessory sciences. But he need not wholly detach 
himself from them ; some one of them may be cultivated along with his 
more serious pursuits. He may devote one session to lectures on che- 
mistry, another to those on botany, a third to physiology, and so on of the 
rest. But his main object must now be the acquisition of practical know- 
ledge, and consequently the greater portion of his time and energies must 
be devoted to the clinical wards and dissecting-room of a hospital, to the 
study of the materia medica and pharmacy in an apothecary's shop, and 
to practical anatomy. Five or six years' attendance on a hospital will 
be little enough to qualify you to enter with propriety and confidence on 
the discharge of your professional duties. Bear in mind, gentlemen, that 
when you come to treat disease, you approach the bedside as physicians 
or surgeons, and not as chemists, botanists, or anatomists. This is the 
character in which you are to appear ; and, to the acquisition of know- 
ledge which will prepare you for the discharge of its duties, you ought to 
engage your chief attention. 

Some of you, gentlemen, may think that it ill becomes a teacher to 
narrow the limits of your exertions, or circumscribe your pursuits. But 
let me be understood. What 1 wish to impress upon your attention is, 
that you ought to address yourselves mainly to the acquirement of what 
is really useful, and should store up chiefly what is most important and 
available. And in furtherance of this object I think it my duty to warn 
you against the well-meaning but injudicious representations of those who 
would turn you from the study of practical matters to the cultivation of 
their favourite sciences — sciences connected with and ancillary to medi- 
cine, but in which medical students are too often encouraged to engage 
with an ardour that indirectly, but certainly, leads to a less zealous and 
efficient attention to more important matters. Take, for instance, two of 
the most popular of the adjunct sciences — two usually regarded as most 



38 ON CLINICAL INSTRUCTION. 

intimately connected with the study of medicine, botany, and chemistry. 
Both are extremely valuable in themselves, and a certain acquaintance 
with them is undoubtedly desirable ; but to the student in medicine their 
utility has been greatly overrated. Botany is an extremely interesting 
and useful science ; but I believe you might be very good practitioners 
without knowing the classes of Linnaeus, or the families of Jussieu. To 
be sure, if you had the misfortune to practise in localities separated from 
the ordinary channels of commerce ; if you were suddenly bereft of the 
numerous stores which maritime enterprise pours into the lap of medicine, 
and obliged, like the herbalists of old, to search the woods and fields for 
your materia medica, you would certainly be often at a loss, and might 
make some serious mistakes, unless you were adepts in practical botany. 
But this labour, fortunately for us and for every European practitioner, is 
quite unnecessary. A small capital will bring the vegetable productions 
of the most distant countries to your door ; and any respectable druggist 
will, for a trifling sum, provide you with all the medical substances de- 
rived from plants, carefully selected and accurately prepared. 

Those who boast the most loudly of their acquisitions in botany, and who 
lay most stress on its importance, know very well that to the physician it 
is of little or no practical value. Take one of the best of our English or 
Irish botanists, and see how meagre a knowledge he possesses after all, 
of many of the plants whose products are employed so largely every day 
in the treatment of disease. Transport him suddenly to the East or West 
Indies, to Africa, or South America, ask him to show you the camphor or 
the cinnamon-tree, the cajuput, the croton, or the guaiacum, — I doubt 
very much whether he would be able to recognise logwood, or even ipe- 
cacuanha, growing in their natural situations. Again, there are a great 
many vegetable productions used every hour in medicine, of which it may 
be said, that no two botanists are agreed as to the precise description of 
plant from which they are derived. There is no substance in such com- 
mon use as gum Arabic, and yet, notwithstanding all that has been writ- 
ten on the subject, it is not clear from what particular plant it is derived. 
Nor do I think it necessary to know whether the gum we use in com- 
pounding a cough medicine comes from the Acacia- vera or Acacia Ara- 
bica. In like manner, the plants which furnish arrow-root and many other 
substances in common use are by no means determined. How many 
disputes have there been with respect to the genus Cinchona ? And what 
has been the result of all our investigations concerning the plant which 
produces this great remedy. Listen to what my late learned friend 
Andrew Duncan says, in the Supplement to the Dispensatory : " Not- 
withstanding that all the British colleges agree as to the botanical species 
of cinchona from which the commercial varieties of bark are derived, 
there is no satisfactory evidence that they are right ; on the contrary it is 
almost certain that in regard to some of them they are wrong." How 
many years were columba and many other similar productions employed, 
before scientific botanists knew any thing of their true history? In 1829 
a paper was read by Dr. Hancock, on the tree which yields the Angustura 
bark ; it appears that even Bonpland and Humboldt had described the 
wrong tree, and consequently it has been called for many years a Bon* 
plandia ; whereas it belongs, it now appears, to another genus, named 
Galipea : it is not a majestic forest tree, eighty feet high, but a very hum- 
ble plant, half tree, half shrub. Dr. Hancock has also proved that the 



INTRODUCTORY LECTURE. ,;9 

Smilax syphilitica of Wildenow is not the true sarsaparilla, which, con- 
sequently, is produced by a plant not yet described ; and at what conclu- 
sion does Dr. Hancock, who spent many years in South America, arrive ? 
Why that the only criterion for knowing good sarsaparilla is its taste when 
chewed! In proof of the uncertainty which still prevails concerning the 
determination of species used in medicine, I have only to refer you to the 
admirable lectures of Mr. Pereira in the Medical Gazette, and those of 
Dr. Sigmond published in the Lancet.* 

I do not wish to undervalue botany as a part of general education. 
Few sciences are more attractive, and few are more likely to become an 
object of enthusiastic pursuit ; but it is the very enthusiasm it is so likely 
to generate that I wish to warn you against. Botany is an excellent ex- 
ercise for the minds of youth : it gives habits of accuracy of observation, 
and tends to strengthen the memory. It leads to healthy occupation, and 
affords a source of innocent enjoyment. As productive of so much good, 
let it form a part of the early education of young persons in general ; sure 
I am that its cultivation would give a healthier tone to both mind and 
body, than are to be obtained from many of the studies with which boys 
are now tortured in the schools. But let botany be restricted within its 
proper limits ; and when once young men have seriously engaged in the 
acquirement of medical and surgical knowledge, let them not entertain 
the ambition of becoming accomplished botanists. 

Speaking of botany, I may observe that it is much to be regretted that 
the names of plants should undergo so many mutations. What was for- 
merly called Stilozobium has successively become Dolichos and Mucuna; 
while Iceland moss has been changed from Lichen into Cetraria, and 

* In the number of ihe Quarterly Review for June, 1812, we find so ;.c very pertinent 
observations upon the ridiculous names given to many flowers, an J the inconveniences likely 
to arise from the frequent changing of them. 

The reviewer says, " Before we have done with the florists and botanists, we must say one 
word about their nomenclatures. As long as the extreme vulgarity of the one and the extreme 
pedantry of the other continue, they must rest assured that they will scare the majority of this 
fastidious and busy world from taking any great interest in their pursuits " 

After objecting to many modern names, he adds, " Surely there is marked character enough 
about every plant to give it some simple English name, without drawing either upon living 
characters or dead languages. It is hard work, as even Miss Mitford has found it, to make the 
maurandias, and alstnemonas, and eschscholtzias— the commonest flowers of our modern gar- 
dens — look passable even in prose ; they are sad dead letters in the glowing description of a 
bright scene in June. But what are these to the pollopostemonopetelae and cleutheromacros- 
temones of Wachendorf, with such daily additions as the native name of iztactepotzacuxochitl 
icohueyo, or the more classical ponderosity of Erisynum Peroflskyanum ] 

" Like the Verbum Grcecum, 

Spermagoiaiolekitholakanopolides, 

Words that should only be said upon holidays, 

When one has nothing else to do. 

"To make confusion worse confounded, our botanists are not satisfied with 

their far-fetched names ; they must ever be changing them too. Thus it is a mark of igno- 
rance in the world of flowers, to call our old friend Geranium otherwise than Pelargonium 
the Glycine (G. Sinensis), the well-known specimen of which, at the Chiswick gardens, pro- 
duced more than 9000 of its beautiful lilac laburnum-like racemes from a single stem, is now 
to be called Wistaria; the new Californian annual ^Enothera is already Godetia ; while the 
pretty little red Hemimaiis, once a (Jelsia, is now (its third designation) an Alonsoa ; and our 
list is by no means exhausted. Going on at this rate, a man might spend the morn of his life 
in arriving at the present state of botanical science, and the rest of his days in running after 
its novelties and changes. We are only too glad when public sanction triumphs over indi- 
vidual whim, and, as in the cases of Georgina proposed for Dahlia, and Chryseis for Eschscholt- 
zia, resists the attempted change." 



40 ON CLINICAL INSTRUCTION. 

Secale cornutum into Acinula clavus. Uva ursi is now preceded by the 
praenomen Arctostaphyllos ; and our old acquaintance jalap, deprived of 
its euphonious prefix Convolvulus, has degenerated into Ipomsea. All 
these changes are useless or injurious, and entail as a necessary conse- 
quence, that the young, the middle-aged, and the advanced in life, use a 
different medical vocabulary. The materia medica, too, as now taught 
by scientific professors, presents a serious stumbling-block to students. 
Teachers do not confine themselves to showing the different drugs and 
preparations, but they enter into very minute details of their natural his- 
tory and characters ; so that the student cannot learn the properties of 
bees'-wax without being entangled in the difficulties of entomology, or 
the nature of isinglass without learning the hard names used in ichthyo- 
logical classification. 

The same observations apply to chemistry. It is a science fully as 
attractive as botany, and medical men are apt to spend too much time in 
its pursuit. Some very pertinent observations on this subject were made 
in the Medical Gazette about five or six weeks ago, to which I refer you: 
they are conceived in a spirit of good sense and sound judgment, and you 
will find them well worthy of an attentive perusal. I grant it may appear 
very like a paradox to say, that you need not know much practical che- 
mistry. But if you go to a reputable druggist with money in your pocket, 
he will furnish you with all the chemicals you have need of, excellent in 
their kind, and prepared with scrupulous exactness. You will get good 
calomel, good sulphate of quinine, and good hydriodate of potass.* So 
far as chemicals are required for medicinal uses, you can have them all of 
the best description. But it will be said that without an accurate and 
extensive knowledge of chemistry you cannot prescribe. This is an 
assertion to which I cannot assent. A very limited knowledge indeed of 
chemistry will enable you to ascertain what substances are compatible 
with each other, and a small share of attention will prevent you from 
making any important mistakes. Besides, you are all aware that many 
of our best prescriptions contain incompatible ingredients; and that many 
compounds which would be sneered at by the mere chemist, as heteroge- 
neous and absurd, prove decidedly efficacious in medicine. Granting that 
a certain degree of chemical knowledge is requisite, it does not follow 
that you should be scientific and accomplished chemists. It is not neces- 
sary that you should dive into all the arcana of the science, or have your 
memories loaded with atonic numbers, symbols, and equivalents. 

Let me repeat with respect to chemistry what has been already observed 
concerning botany. Students should attend one or two courses of this 
science as preparatory to the study of medicine, and during the period of 
that study they may attend another, in order to keep up and improve their 
knowledge ; but they should never allow chemistry to cause them to ab- 

* The reader will perceive, from the following extract, that I now speak of the hydriodate of 
potash sold in this city. That which is used at the Meath Hospital is prepared by Mr. Hunt, 
and I believe what Mr. Allen sells is equally good. 

Dr. Christison, in his valuable " Dispensatory," states that this medicine " is exceedingly 
subject to adulteration, both from faulty manufacture, and from fraudulent admixture. The 
principal adulterations hitherto observed are with carbonate of potash, water, chloride of potas- 
sium or sodium, and iodate of potash. 1- Carbonate of potash is very generally present to 
between one and five or even ten per cent., owing, in all probability, to errors in preparing the 
salt; but I have sometimes found 74-5 per cent, of carbonate, and 16- of water along with it, 
so that there was only 9-5 per cent, of pure salt — an amount of impurity which could have 
arisen only from fraud on the part of the maker." — Page 753. 



INTRODUCTORY LECTURE. 41 

sent themselves from the hospital for a single day. Theoretical and phi- 
losophical call for your attention less than animal and pharmaceutical 
chemistry. But you are told that you may be called on to decide ques- 
tions of medical jurisprudence, which demand an accurate knowledge of 
chemistry ; that you will be required to test poisons, and detect them 
when accidentally or purposely mixed with food or drink. What should 
you do in such cases ? Why, do not undertake any investigations of the 
kind, refuse to make them, refer them to those who are competent to the 
task. Where will you find a man engaged in the practice of physic fully 
capable of deciding such questions? What practising physician or sur- 
geon is competent to enter at once upon an investigation of this nature ? 
I have lectured some three or four years on medical jurisprudence, and 
bestowed a good deal of attention on the subject, and yet if called on to 
decide a case of poisoning, I would refuse, and say I was incompetent to 
the task. What then is to be done under such circumstances? This is 
a matter of deep importance to society. It is of the utmost consequence 
that the wretch who poisons should not escape, and that the innocent 
should not suffer. It therefore behooves the Government to employ and 
pay persons capable of deciding such questions. Then, and not till then, 
will the task be duly performed, and the decisions be such as the public 
can look up to with respect and confidence. 

So far with respect to a knowledge of chemistry as connected with the 
choice and prescription of medicines, or the analysis of poisons. As to 
any benefits derived from analytic chemistry in solving the problems of 
vital action, or elucidating the functions of the various organs in health 
and disease, they may be said to be few and unimportant, and inconclu- 
sive. Few and scanty, indeed, are the rays of light which chemistry has 
flung on the vital mysteries. I am not aware that it has revealed any of 
the master secrets of the organism, or detected the sources of those im- 
portant aberrations from normal action which we are called on to study 
every day and every hour. Chemistry has failed most remarkably in 
revealing the arcana of life ; and notwithstanding all her boasted disco- 
veries, we are still very little in advance of those who practised the heal- 
ing art some centuries ago. Chemists, the ablest of their class, have 
bestowed the most minute and unwearied attention on the analysis of 
fibrin, and gelatin, and albumen; and what have they discovered? 
Simply this: that substances so apparently distinct in their vital relations, 
and so different, or even opposed, in their physical properties, are analo- 
gous compounds ; that there is scarcely any difference in their elementary 
composition ; and that their atomic constitution is nearly identical. How 
long have chemists laboured in attempting to detect the cause of animal 
heat ! How many experiments have been made for the purpose of ascer- 
taining the effect produced on the air by respiration! How many able 
and ingenious men have sought a chemical explanation of the difference 
in point of colour between arterial and venous blood ! All these investi- 
gations have proved indirectly useful, but none of them have revealed the 
secrets sought ; and we are still in profound ignorance of the powers 
which direct and modify the unceasing operations of the laboratory over 
which life presides — that mysterious influence which, like the Deity from 
whom it emanates, is invisible, inscrutable, incomprehensible. 

So much for the light which chemistry has shed on the vital actions, 
and on the nature of organised compounds. There are, to be sure, one 
or two instances in which a rough examination of some organic products 



42 ON CLINICAL INSTRUCTION. 

is necessary ; as, for example, of the urine, in certain cases of gout, gra- 
vel, and dropsy. But even in these instances, a few simple rules will 
suffice, and sufficient information may be obtained by one moderately 
acquainted with chemistry. Generally speaking, the chemical knowledge 
requisite for the study of disease is very limited ; and those who are en- 
gaged in the practice of medicine are well aware, that cases demanding 
an accurate or extensive knowledge of chemistry are of extremely rare 
occurrence. 

Let me now advert to a serious inconvenience which the chemists have 
imposed upon the medical world. They have, it appears, not only assumed 
to themselves the privilege of naming our medicines, but also of changing 
those names every five or six years. One of my ablest and most diligent 
pupils (Mr. Moore) has taken the trouble of drawing up a table, showing 
the various names which have been successively bestowed on each sub- 
stance since the days of Lavoisier. I have the table here before me, and 
I find that most chemical substances' have, in the space of fifty years, un- 
dergone at least five changes. Of course, as the march of chemistry pro- 
gresses with accelerated speed, we may give our nomenclatures credit 
for an increased tendency to revolutionise the chemical vocabulary, and 
conclude that they will change them five times within the next fifty years. 
In 1890, how will a man be able to recognise a substance whose name 
has undergone ten mutations ? I am anxious to dwell on this defect as 
being pregnant with perplexity and confusion. It would almost seem as 
if some enemy to our profession had invented the chemical nomenclature 
for the purpose of retarding the advance of practical medicine. Of what 
use will a Practice of Physic, published in 1800, be to the reader who 
peruses it in 1900 ? We all know how easily the mind of man is deterred 
by difficulties ; how few there are who will submit to the labour of be- 
coming genealogists in chemical names. 

Many and able men foresaw this difficulty from the beginning, and raised 
their voices against the adoption of names meant to convey a knowledge 
of the chemical composition of mineral and saline medicines. Bostock 
and Murray have both written ably on this subject, and I regret much that 
their advice has not been duly weighed and considered. In practice, 
many serious inconveniences arise from this vacillating state of chemical 
nomenclature. Every apothecary knows that mistakes occur from day to 
day, owing to the shifting character of chemical nomenclature, and I think 
it is time for us to bestir ourselves, and make a stand against the useless 
and dangerous innovations of the chemists. We should come forward 
boldly, and declare that we will not be made the slaves of names. Com- 
pare our last Pharmacopoeia with its immediate or penultimate predecessor, 
and the difficulties a physician has to encounter will be obvious. Are we 
to be perpetually called on to learn new names? Must an artificial me- 
thod of forgetting become even more necessary than a memoria technical 
Must my prescriptions of 1818 be translated into a new language, if I wish 
to employ them now ? It is time, then, to protest seriously against having 
our memories loaded with a polyglot vocabulary, and our ideas confused 
by a perpetual alteration of names. I do therefore assert boldly, that 
much benefit would accrue from reverting to the old system, and employ- 
ing names which have no direct reference to the substances. I do not 
see any reason why we should not continue to call calomel, calomel ; nor 
do I see any advantage in giving it any of the numerous modern appella- 
tions supposed to indicate its chemical constitution. I am glad to find 



INTRODUCTORY LECTURE. 43 

that this view of the subject has the able support of Dr. Sigmond. He 
quotes Professor Brande as being of opinion that u it is very inconvenient 
to alter pharmaceutical terms according to the changes in chemical nomen- 
clature ; and as physicians in practice have not come to accord in this 
particular, I can see no objection to the term calomel for one substance, 
and corrosive sublimate for the other, pharmaceutteally speaking." Jt is 
a subject of deep regret, adds Dr. Sigmond, that the attempt should be 
made, because it never can be successful; for some chemists will call 
calomel protochloride, others chloride, and some denominate sublimate 
■per chloride, others deuto chloride, and others again, as does the Royal Col- 
lege of Physicians, bichloride. 

What is the use of a name ? To designate a thing — to point out any 
substance, so that when we call for it we may get it, and nothing else. 
This is all that is necessary. When you tax a name beyond this, you 
exceed the limits cf ordinary language, and demand too much. The old 
names for our medicines are not inferior, in this respect, to the modern 
ones imposed on us. by chemists. Tartar emetic is a good and significant 
name, and yet I perceive it has been altered several times before, and 
again in the last edition of the London Pharmacopoeia. Why is it that 
the preparation of bismuth used in pyrosis has been three times changed 
in my own memory ? What alterations have not the carbonates of iron 
and of alkalies undergone ? As for Fowler's solution, corrosive sublimate, 
Mindererus's spirit, and /Ethiop's mineral (all good standard names), they 
are now nearly extinct, and have been superseded by a new generation 
likely to prove as unstable as their predecessors. Many other substances 
have undergone the same fate. Where will the revolution stop? Indeed 
we seem, at the present moment, as far removed as ever from the estab- 
lishment of a stable system of chemical names. The progress of investi- 
gation discloses almost daily new views of the mutual relations between 
the elements constituting compound bodies; the atoms associated together 
are divided and subdivided into new groups, and, consequently, the sym- 
bolical representation of every compound assumes a new configuration, 
and is subdivided by brackets, altering their places with each successive 
advance of science. The labours of BornsdortT and Hare already threaten 
the nomenclature of Berzelius, and the chlorure platinosopotassique of the 
latter, now considered as a compound of chloroplatinous acid and the 
chlorobase of potassium, must then be called chloroplatinite of potassium. 

If chemical names are still to be formed with the view of expressing 
chemical composition, there is no end to the complication and length at 
which they must arrive. If they express composition, it is worse than 
useless, were they to do so incompletely. A name whose structure de- 
signates the nature of the thing named, must, in chemistry, to be service- 
able, designate it with perfect accuracy. Professor Kane has analyzed, 
in one of his very able papers, a crystalline substance obtained by boiling 
the white ammonia subnitrate of mercury with solution of ammonia. Sup- 
pose this substance to be introduced into the Pharmacopoeia, how can it 
be named in conformity with the principle which attempts to make each 
name expressive of the composition of the matter named ? its composition 
is stated by Professor Kane to be — one atom of nitrate of the oxide of 
mercury, plus two atoms of oxide of mercury, plus one atom of amide of 
mercury, plus two atoms of the nitrate of the oxide of ammonium, plus 
two atoms of the oxide of hydrogen. Even if the ingenuity of chemists 
had surmounted the difficulty of inventing a name capable of expressing 



44 ON CLINICAL INSTRUCTION. 

the nature, number, and mode of aggregation of the above elementary 
atoms, is it probable that a name, so gifted, would be of a length ma- 
nageable by either the tongue or the memory ? Is it certain that future 
experiments may not unfold new views concerning the arrangement of 
the constituent atoms, and thus nullify the old, by requiring the adoption 
of a new designation ? 

In order to exemplify how much physiology and pathology are indebted 
to the researches of chemists I beg to quote at length from the Quarterly 
Review, June, 1842 (p. 99, and p. 121). 

" Professor Liebig applies the name of metamorphosis to those chemical 
actions in which a given compound, by the presence of a peculiar sub- 
stance, is made to resolve itself into two or more compounds, e. g. sugar 
by presence of yest, into alcohol and carbonic acid. 

" Now putrefying animal matters will cause sugar to ferment as well as 
yest — explanation, the ferment or exciting body is invariably a substance 
in an active state of decomposition, and therefore its particles in motion ; 
this motion is communicated to the particles of the body to be metamor- 
phosed, and is sufficient to overturn their very unstable equilibrium, and 
to cause the formation of new and more stable compounds. Liebig ex- 
plains the action of certain medicines and poisons on the human body in 
the same way — thus there are many medicines and poisons which produce 
a very marked effect without their elements taking a direct share in the 
changes which ensue ; those bodies originate, as it were, an action, which 
is subsequently propagated from particle to particle ; they are uniformly 
substances in a state of change, and appear to act on the blood, as yest 
does on a solution of sugar. In this class appear miasms, contagions, and 
the similar sausage poison of Wurtemberg ; the latter is an excellent ex- 
ample. Sausages, made in a peculiar way, are much used in that coun- 
try ; when ill-prepared they become poisonous, and their effects are inva- 
riably fatal : the patient gradually dries up into a sort of mummy, and 
after weeks or months of misery, death closes the scene ; but there is no 
poisonous substance to be detected in the sausage. It is, according to 
Liebig, in a peculiar state of fermentation, which is not checked by the 
action of the stomach, and which unfortunately is communicated to the 
blood ; it never ceases until every part capable of solution has been de- 
stroyed, and death of course must follow. Miasms and contagions act on 
the very same principle, and the reason that all are not affected by them 
seems to be, that they require the presence of a peculiar compound in the 
blood, which enters into decomposition, and when the whole of this pecu- 
liar matter is destroyed, the disease disappears. If there be much such 
matter the case is severe, if little, the case is mild; and apparently in 
many contagious diseases, the peculiar decomposable matter once destroyed 
can never be renewed, so that these diseases occur but once." 

Such is Professor Liebig's theory of poisoning and contagion — a theory 
which, though it comes to us recommended by the abilities of the first 
organic chemist of the age, and sanctioned by his anonymous but able 
reviewer in the Quarterly, can nevertheless be easily proved to rest upon 
almost as many assumed as proven facts. Thus how can Liebig so posi- 
tively assert that there is no poisonous substance in the fatal sausages ? 
True it is that no chemist has yet insulated such a substance ; but Liebig 
knows better than any one else how profoundly concealed any particular 
animal principle may be by being mixed with a great variety of other 



INTRODUCTORY LECTURE. 45 

animal principles. Thus how long did sugar, in the blood of diabetic 
patients, elude the researches of chemists ? and yet they were looking for a 
principle with whose chemical qualities they were already accurately ac- 
quainted. How much more difficult of detection must the poisonous prin- 
ciple be which exists in so compound a body as a Wiirtemberg sausage ? 
Besides, what chemist was ever sure that he was actually analyzing a poi- 
sonous sausage ? Here a special difficulty lies, for hitherto there has been 
discovered no a priori method of distinguishing a poisonous from a whole- 
some sausage until both have been eaten, that is, too late for analysis. 
How long has the poisonous quality of ergot of rye been known r and yet 
the principle to which its effects are owing, though often sought, has been 
only lately insulated. 

It is obvious, therefore, that Professor Liebig's main example of his 
new pathological explanation is not by any means proven, and conse- 
quently it is unnecessary to follow him into the regions of fancy where 
he has been enticed by a specious and seductive analogy. Pathology 
will cease to be a science when the study of facts gives place to such 
reveries as the above cited passage contains — relative to miasms, conta- 
gions, mild cases, severe cases, diseases occurring but once in life, &c, 
&c, &c. And yet I am sorry to say that one of our most distinguished 
lecturers, Dr. Watson, has, in the number of the .Medical Gazette for July 
29, 1842, fully adopted these opinions. 

In order to give the reader some idea of what Dr. Watson considers to 
be u distinct conceptions" and " tights supplied by a theory," I beg leave 
to quote from the Doctor's lecture the following paragraphs : — 

" Moreover, the light supplied by this theory gives distinctness to our 
conceptions respecting certain deviations from the regular course and 
type of these diseases ; which deviations are not uncommon. 

"Thus the symptoms which precede and usher in the eiuption are 
sometimes slow, halting and irregular in their progress ; appear, and then 
recede, and reappear, so that we are in doubt what is about to happen, 
until at length the disease declares itself in its decided and authentic 
form. 

" We may suppose this to depend upon some tardiness or interruption 
of the process, whereby the virus is (to use the ancient term) concocted. 

" Again, the series or combination of symptoms that mark the specific 
disease is sometimes, as I stated before, incomplete. We have the erup- 
tion of measles without the catarrhal symptoms ; the sore throat without 
the rash, of scarlet fever. And experience has found that, where the 
malady is thus imperfectly developed, the protection it confers against its 
own recurrence is also incomplete. To explain this double failure we 
may reasonably infer a corresponding defect in the series of changes 
which the poison tends to produce in the mass of the blood. 

" Glandular enlargements and chronic abscesses are frequent sequelx of 
these exanthematous disorders. They may be considered to represent 
the dregs of the reproduced virus, which has been imperfectly eliminated 
from the system by the usual channels." 

Very few observations are called for by these surmises of Dr. Watson ; 
and certainly the learned Doctor is rather guarded in his expressions, 
thus admitting that though he has given in his adhesion to Liebig's theory, 
yet he seems to view the deductions to which it leads with considerable 
distrust. Indeed it is difficult to rest satisfied with reasoning which not 



46 ON CLINICAL INSTRUCTION. 

only assumes gratuitously a certain thing to be the cause of a certain 
effect, but considers it a corroboration of that assumption, that whereas 
the effect is irregular in its progress we may suppose the cause is so like- 
wise. 

It is still a greater triumph of logic to infer that because a disease is 
incomplete that we gain any thing towards the establishment of the true 
nature of its cause by saying that we may reasonably infer that a corre- 
sponding defect exists in the cause itself. To me the whole line of argu- 
ment appears delusive, and as to the last paragraph concerning glandular 
enlargement and chronic abscesses, it seems that Dr. Watson's conclusion 
involves a contradiction, for he attributes to the virus itself, and that by 
virtue of its chemical action, the production of several exanthematous 
diseases, each specifically distinct, and indeed as different from each 
other as an acid from an alkali, while to .the dregs of the reproduced 
virus, he attributes sequelae — those glandular enlargements and chronic 
abscesses which so frequently appear after small-pox, scarlatina, or 
the measles. According to this hypothesis, three different animal poi- 
sons, all acting chemically, produce at first three different diseases, and 
at last the same disease. With regard to this hypothesis, I may fur- 
ther remark, that when a brewer takes a certain quantity of sweet wort, 
puts it in a vessel, and adds a given portion of yeast* to it, he knows that 
if he simultaneously fills in the same way fifty similar vessels, the process 
of fermentation will produce in each thirty times as much yeast as was 
originally added to the wort. But when the virus of small-pox is introduced 
into the blood of fifty individuals, is a multiplication of the small-pox mat- 
ter thus proportioned to the quantity of blood in each ? It certainly is 
not ; a fact conceded by the supporters of Liebig's hypothesis, but which 
they try to evade by saying that the particles of the blood which are sus- 
ceptible of this particular decomposition and metamorphosis exist in dif- 
ferent proportions in different individuals. 

This method of ratiocination is as inconclusive as it is novel, and may 
be aptly termed, arguing not in but outside of a circle. 

The following quotation, taken from the Provincial Medical Journal, 
contains a condensed but very accurate analysis of Liebig's theory of 
heat, and the pathological inferences Which necessarily appear to flow 
from it : — 

"The carbon and hydrogen of food, in being converted by oxygen into 
carbonic acid and water, must give out as much heat as if they were 
burned in the open air. The only difference is, that this heat is spread 
over unequal spaces of time ; but the actual amount is always the same. 
The temperature of the human body is the same in the torrid as the frigid 
zone. But as the body may be considered in the light of a heated vessel, 
which cools with an accelerated rapidity the colder the surrounding me- 
dium, it is obvious that the fuel necessary to retain its heat must vary in 
different climates. Thus, less heat is necessary in Palermo, where the 
temperature of the air is that of the human body, than in the polar regions, 
where it is about 90° lower. In the animal body, the food is the fuel ; 
and, by a proper supply of oxygen, we obtain the heat given out during 
its combustion in winter. When we take exercise in a cold atmosphere, 

* We are glad to find Dr. Watson adhering to the old spelling of this word. He spells it 
as De Foe spells it in his Robinson Crusoe ; this authority is probably as good as any writer 
in the Quarterly Review could bring forward in support of his yest. 



INTRODUCTORY LECTURE. 47 

we respire a greater amount of oxygen, which implies a more abundant 
supply of carbon in the food ; and, by taking this food, we form the most 
efficient protection against the cold. A starving man is soon frozen to 
death ; and every one knows that the animals of prey of the arctic regions are 
far more voracious than those of the torrid zone.* Our clothing is merely 
an equivalent for food ; and the more warmly we are clothed the less food 
we require. Were we to go destitute of clothes like certain savage tribes 
— or if, in hunting or fishing, we were exposed to the same degree of 
cold as the Samoyedes — we could, with ease, consume 10 lbs. of flesh, 
and, perhaps, a dozen tallow candles into the bargain, as warmly clad 
travellers have related, with astonishment, of those people. Then could 
we take the same quantity of brandy or blubber of fish without bad effects, 
and learn to appreciate the delicacy of train oil. 

" We thus perceive an explanation of the apparently anomalous habits 
of different nations. The maccaroni of the Italian, and the train oil of 
the Greenlander and the Russian, are not adventitious freaks of taste, but 
necessary articles fitted to administer to their comfort in the climates in 
which they have been born. The colder the region, the more combusti- 
ble must the food be." 

It is, I must confess, quite new to me that our clothing is merely an 
equivalent for food, and the more warmly we are clothed the less food we 
require. Take the well-clad and warmly-clothed country squire, and 
compare the quantity of food he devours with that which is consumed by 
his ragged labourers, and it may be asserted that the balance will be as 
much in favour of the squire's food as of his raiment. The voracious 
Samoyedes referred to, however barbarous in their manners, are an extra- 
ordinarily warmly clothed race, and the semi-putrid fat and blubber of 
whales, agrees w 7 ith the stomach of the Laplander as well in the heat of 
summer as in winter. In the arctic and cold regions of the earth man is 
driven by necessity to subsist on animal food, which is supplied to him 
by the unfrozen depths of the ocean, for in those inhospitable regions 
vegetable life is almost a stranger, and therefore it is that the Laplander, 
the Greenlander, and Samoyede subsist almost exclusively on animal 
food. In the expeditions of Franklin, Parry, and Ross, our countrymen 
braved all the rigours of an arctic winter on the same food which they 
were in the habit of consuming in milder climates ; and if it be true, as 
stated in the above passage, that in the animal body the food is the fuel, 
and, by a proper supply of food, we obtain the oxygen given out by its 
combustion in w T inter ; if this be true, it is strange that there is no record 
of its being found necessary to give our sailors more food during the 
extreme cold than at other periods. 

Facts are wholly inconsistent with many of Liebig's allegations. All 

* I cannot guess how every body comes to know all this; for my own part. I think it may 
be maintained that a Bengal tiger, or Uape hyena, requires, in proportion to its size, quite as 
abundant rations as any of the arctic camivora ; and as to the vultures of Hindostan and Per- 
sia, where on earth, in air, or in water, can be found such gluttons ? IVeither do I think that 
any one (not to say every body) would be prudent in counting on the abstinence of a shark, 
even within the tropics ! Although religious ordinances prevent the Hindoos from eating beef, 
yet both they and the Arabs occasionally devour mutton in astonishing quantities. Those who 
ride over the Pampas in tSouth America, at the rate of 100 miles a-day, exposed to a burning 
sun, subsist entirely on boiled beef and water, without a particle of vegetable food of any kind, 
and yet they attain to an extraordinary condition, and capability of enduring violent and long- 
continued exertion. Liebig's theory must be very ductile, if it can explain how it happens 
that an exclusively animal diet agrees with man quite as well at the equator as within the 
arctic circle. 



48 ON CLINICAL INSTRUCTION. 

hunting tribes of mankind, whether in northern, temperate, or tropical 
regions, subsist chiefly on animal food. This is true of the North and 
South American Indians, and it is true of the Hottentots, and indeed our 
travellers relate prodigies of gluttony enacted by the latter, for when, after 
a long fast, they suddenly obtain abundance of game, they will sit up the 
whole night occupied in cooking and devouring steak after steak unac- 
companied by a morsel of vegetable food, and at such times, so indefati- 
gable are they in the business of eating, that the party which over night 
had tightened their famine girdles to the last hole, have enormously dis- 
tended abdomens on the following morning, this, too, in the heat of Africa, 
where certainly no additional food was required for supporting the animal 
temperature. If Liebig's theory be correct, that animal food is peculiarly 
adapted to cold climates, how comes it that the most voracious carnivorous 
animals abound in the hottest regions of the earth. The Bengal tiger, 
and the African lion, and the boa constrictor of South America, together 
with alligators and crocodiles of the Nile, the Ganges, and the Oronooko, 
all subsist solely upon animal food ; and on the other hand, among the 
whale tribe it is observable that they abound in every variety of oceanic 
temperature, where the appropriate animal food occurs, and the same 
observation applies to fishes in general. Take the antelope and the 
gazelle of Africa, which w T ould shiver from cold during the warmth of an 
English summer, and compare them with the reindeer, that bears with 
impunity, and that for months together, a temperature far below zero, and 
how can we explain the difference by Liebig's theory, for they both sub- 
sist on vegetable food ? Facts such as these are not merely irreconcile- 
able with, but destructive of, that theory. 

I would not be understood here as wishing to depreciate any depart- 
ment of human knowledge. Far be it from me. Besides, the attempt 
would be useless. But I am anxious that you should concentrate all your 
energies on the proper objects of medical pursuit, and devote the largest 
share of your attention to those acquirements which will render you good 
practitioners. 1 have seen students led astray by false notions, wasting 
half of the time which should be spent in hospital, and by the sick bed, 
in wandering through the fields on botanical excursions, or working in the 
laboratory, engaged in the solution of some unimportant problem. Now 
this is not what will teach them to relieve suffering, and cure disease. 
When I look round me, and behold so many young gentlemen entering 
upon an honourable and important profession, I feel that my responsibility 
is great. I consider you all as instruments of good or evil, and cannot 
help being conscious that I should be guilty of a great crime, did I not 
use every means in my power to render you able and efficient practitioners. 
The teacher of clinical medicine, gentlemen, occupies in every nation a 
post of heavy responsibility. But when he happens to preside over the 
medical education of those w T ho resort to the wards of a metropolitan hos- 
pital — when the metropolis is a British one, and the hospital destined to 
send forth annually practitioners to every quarter of the globe — to North 
and South America, to $ew Holland, to the Cape of Good Hope, to the 
East and West Indies, and the countless isles which, in either hemisphere, 
are visited by the British flag, then indeed does that teacher become himself 
an instrument of good or evil, to an extent which it is fearful to contemplate. 

He who gives instruction to a clinical class in Berlin, Stockholm, Vienna 
or Paris, has much to answer for, if he discharge not his duties with zeal 



INTRODUCTORY LECTURE. 49 

and diligence. Yet if he fails to make his pupils good practitioners, their 
errors, however deplorable, are circumscribed within comparatively narrow 
bounds, and limited in a great degree to their own countrymen. But the 
British teacher sits in the centre of a circle far wider than Sweden or 
Prussia, Austria or France ; his pupils are to be met with practising in 
every climate, exercising their art in almost every habitable region of the 
globe and dispensing the blessings of health to all races of mankind ; — to the 
hardy white settlers of Canada, the aboriginal red-skins of North America, 
the Negroes of Jamaica, the Hottentots and Caffres of Africa, and the count- 
less tribes of Hindostan. 

In truth, gentlemen, the British teacher of practical medicine exercises 
an influence without parallel in importance and extent, and his opportuni- 
ties of benefiting or injuring his fellow-men are incalculably great. If he 
neglects his duty, if he teaches erroneously, his negligence and bis errors 
in practice are multiplied indefinitely, by means of those whom he ought 
to have better instructed; the scene of his guilt — for it deserves no better 
name — becomes fearfully enlarged, for there is no country so remote that it 
may not contribute victims to the incapacity of his pupils. But if, on the 
contrary, he works with zeal and diligence; if he labours conscientiously 
and perseveringly in performing the important task he has undertaken, a 
compensation awaits him, to which scarcely any member of any profession 
can attain. Can any reward exceed ill value the reflection that he has 
assisted, materially assisted, in imparting practical knowledge to multitudes 
of enterprising young men, who, year after year, leave our hospitals to 
engage in the sacred duties of the medical profession, throughout the 
world? Is it not a high privilege to be enabled to combat death, and con- 
quer disease, as it were by proxy, in so many dilferent localities? Can 
man enjoy a purer, prouder, more gratifying reflection? When I hear that 
a favourite pupil who has acquired a solid stock of practical knowledge 
in this hospital, has settled in any particular town or district, I cannot 
help feeling, on the part of my colleagues and myself, that we have been 
the humble means of conferring a blessing on the people intrusted to his 
care; and I cannot refrain from congratulating myself upon holding a situa- 
tion which multiplies a thousand-fold our efforts to be useful, and enables 
us to stretch forth our hands to heal men of all nations and languages. 
The hero and the despot may extend a sovereignty over distant regions — 
may exert an unlimited control over millions of vassals — may dispense 
honours and rewards, or inflict punishment and death; they may, like 
Alexander, grieve at the narrow limits of a conquered world, and sigh 
for other scenes of glory ; — but they cannot chase away pain; they cannot 
bid the burning thirst to cease, or give back repose to the^leepless: they 
cannot impart feeling or motion to the paralyzed, or sight to the blind ; and 
above all they cannot imitate that almost godlike function of the healing 
art, by which man isenabled to recall tohis fellow-man reason longbanished, 
and restore to society the hapless victim of insanity. 

Gentlemen, the profession we have embraced is the noblest that can 
engage the mind of man, when diligently cultivated and conscientiously 
practised ; but it requires great and persevering industry to enable the stu- 
dent to master all the difficulties that beset his path. Feeling this strongly,. 
I have trespassed perhaps too long on your attention; but I thought it my 
duty to lay before you, as fully as I could, those views which I deemed best 
calculated for your adoption in the acquirement of practical knowledge * 
5 



50 ON CLINICAL INSTRUCTION. 



LECTURES ON FEVER. 



LECTURE IV. 



General Observations— Reports of Mortality from Fever in Ireland— Importance of the study 
of Fever — Typhus Fever an essential disease — Contagious — Treatment — Proper choice of a 
Nurse and Assistants— Air of sick chamber — Necessity of attending to Diet, &c. &c. 

Before entering on the treatment of Typhus Fever, I wish to make a few 
preliminary observations upon its nature and peculiar characters. In the 
first place, typhus fever is endemic in this country; at no period from the 
earliest records down to the present, has it been entirely absent — a fact 
of which you can easily satisfy yourselves by consulting our old authors, 
and by referring to the annual reports of the fever hospitals, established 
through different parts of Ireland. Fever, as I have said, is always en- 
demic in Ireland, but occasionally for one year or one season, or a succes- 
sion of years or seasons, it becomes much more than usually rife, and then 
is said to be epidemic. In my report of the Fever which devastated the 
west of Ireland in 1822, I advanced the opinion that such epidemics are 
brought on by a great dearth of provisions, and their unwholesome quality. 
These are, no doubt, aggravating circumstances, but that they are not the 
sole or even the chief causes of typhus epidemics, is evident from what I 
have since frequently witnessed, viz. the occurrence of fever epidemics 
during years of plenty, of which 1826 was a remarkable example. 

That fever, in Ireland at least, depends on some general atmospheric 
change, which affects the whole island simultaneously, independent of 
situation, aspect, height above the level of the sea, dryness or moisture of 
the soil, or any other circumstance connected with mere locality, is proved 
by the fact, that when typhus begins to increase notably in the Dublin hos- 
pitals, we may always rest assured that a nearly simultaneous increase of 
fever will be observed in Cork, Gal way, Limerick, and Belfast, as I have 
on more than one occasion ascertained by writing to the physicians of fever 
hospitals in those cities. 

For a considerable period there was a great tendency among physicians 
to refer the origin of typhus, and almost every variety of fever to malaria, 
or unwholesome emanations from the soil, produced by the decomposition 
of vegetable matter. In Ireland facts do not bear out this hypothesis, for 
as already stated, when an epidemic of fever has become established, it 
breaks out simultaneously in situations* the most different, and in some 
where no such emanations can be supposed to exist. Thus I have seen a 
whole family affected in the telegraph, situated at the summit of Killiney, 
a mountain formed of bare granite — and indeed the granite and mountain 
districts beyond Rathfarnham, Tallaght, and Killikee, supply the Meath 
Hospital with its worst cases of typhus. The malarious origin of fever in 
general, has, I may remark, become much less probable since the publica- 
tion of the official documents connected with the sickness and mortality of 
the British troops in the Colonies, and from which, as Major Tulloch reports, 
it clearly appears that fevers of the most malignant character frequently 



FEVER. 51 

arise in places presenting, to all appearance, a combination of circumstances 
most favourable to the exclusion of malarious influence, while fever is never 
endemic in other stations, where all the reputed sources of malaria exist 
together. 

There can be no doubt that in Ireland, as in other countries, the effects 
of cultivation and drainage on the health of the inhabitants are very re- 
markable, and I myself have witnessed several exemplifications of the im- 
provement in the public health thus effected. Formerly ague was of rather 
common occurrence in some marshy districts in the immediate vicinity of 
Dublin, and consequently when I was a pupil, cases of intermittent fever 
were constantly to be met with in the hospitals ; now the low grounds have 
been drained, and thus the production of ague has been entirely arrested. 
It may be cited as a proof of the former frequency of ague in Dublin, that 
when sulphate of quinine had been discovered in France, we in Ireland 
were among the first British physicians, who verified its anti-aguish powers, 
and Doctor Barker and I, each of us published tables of many cases of 
ague cured in hospital by that remedy. If I am not mistaken, the first 
dose of sulphate of qwinine ever administered in Ireland was by myself, at 
the Drumcondra Fever Hospital. It is now generally admitted that drain- 
age greatly improves the health of the public; and this opinion has lately 
received additional support from the investigations of Mr. Chadwick, rela- 
tive to the sanatary condition of the labouring population, from whose work 
the following passage is extracted: — 

" In considering the circumstances external to the residence which 
affect the sanatary condition of the population, the importance of a general 
land drainage is developed by the inquiries as to the causes of the pre- 
valent diseases, to be of a magnitude of which no conception had been 
formed at the commencement of the investigation : its importance is 
manifested by the severe consequences of its neglect in every part of the 
country, as well as by its advantages in the increasing salubrity and pro- 
ductiveness wherever the drainage has been skilful and effectual. The 
following instance is presented in a report from Mr. John Marshall, jun., 
the clerk to the union in the Isle of Ely : 

" It has been shown that the Isle of Ely was at one period in a desolate 
state, being frequently inundated by the 'upland waters, and destitute of 
adequate means of drainage ; the lower parts became a wilderness of 
stagnant pools, the exhalations from which loaded the air with pestiferous 
vapours and fogs ; now, by the improvements which have from time to 
time been made, and particularly within the last fifty years, an alteration 
has taken place which may appear to be the effect of magic. By the 
labour, industry, and spirit of the inhabitants, a forlorn waste has been 
converted into pleasant and fertile pastures, and they themselves have 
been rewarded by bounteous harvests. Drainage, embankments, engines, 
and enclosures have given stability to the soil (which in its nature is as 
rich as the Delta of Egypt) as well as salubrity to the air. These very 
considerable improvements, though carried on at a great expense, have 
at last turned to a double account, both in reclaiming much ground and 
improving the rest, and in contributing to the healthiness of the inhabi- 
tants. Works of modern refinement have given a totally different face and 
character to this once neglected spot ; much has been performed, much 
yet remains to be accomplished by the rising generation. The demand for 
labour produced by drainage is incalculable, but when it is stated that 



52 ON CLINICAL INSTRUCTION. 

where sedge and rushes existed but a few years since we now have fields 
of waving oats and even wheat, it must be evident that it is very great. 

" On reference to a very perfect account of the baptisms, marriages, 
and burials, in Wisbech, from 1558 to 1826, I find that in the decennial 
periods, of which 1801, 1811, and 1821, were the middle years, the 
baptisms and burials were as under : — 

Baptisms. Burials. Pop. in 1801. 

1796 to 1805 1,627 1,535 4,710 

1806 to 1815 1,654 1,313 5,209 

1816 to 1825 ...... 2,165 1,390 6,515 

"In the first of the three periods the mortality was 1 in 31 ; in the 
second, 1 in 40; in the third, 1 in 47 ; the latter being less than the 
exact mean mortality of the kingdom for the last two years. (See 
Registrar-General's Second Report, p. 4, folio edition.) These figures 
clearly show that the mortality has wonderfully diminished in the last 
half-century, and who can doubt but that the increased salubrity of the 
fens produced by drainage is a chief cause of the improvement." 

Evidence of a similar nature is given with reference to various parts of 
England. 

In the reports given from the parish ministers in the statistical accounts 
of Scotland, the effects of drainage upon the general health of the popu- 
lation are strongly marked in almost every county, expressed in notes 
made from an examination of the returns. Sutherland — Parish of Rogart : 
u Healthy, and a good deal of draining." Far : " Subject to no particular 
disease; a deal of draining." Ross and Cromarty — Alness: Dry and 
healthy, " climate improved by drainage." It is to be understood that 
drainage appears to form the essential part of agricultural improvement, 
which is connected with the improvement of health. Thus the notes from 
another parish in the same county, Kilmuir Wester and Suddy, states it 
as " healthy ; great improvement ; scarcely an acre in its original state." 
Rosmarkie : "Healthy; agriculture much improved." Elgin — New 
Spynie : "Healthy: much waste reclaimed, much draining." Alves: 
" Dry and healthy, well cultivated, wood sometimes used for drains." 
Banff — Deckford : " Healthy, and people long-lived ; much draining." 
Kincardine — Fordoun : u So much draining that now no swamps : for- 
merly agues common, now quite unknown." Angus Carmylie : " Health 
improved from draining." Kinross — Kinross: " Agues prevalent sixty- 
years ago in consequence of marshes now never met with." Oswell : 
" Ague prevailed formerly, but not since the land was drained." Perth 
Methven : " The north much improved by draining." Redgorton : 
" Healthy ; no prevailing disease ; ague was frequent formerly, but not 
since the land has been drained and planted." Moneydie : "Healthy; an 
immense improvement by draining." Abernyte : " Since the land was 
drained, scrofula rare and ague unknown." Monzie : " Healthy ; a good 
deal of land reclaimed." Aucbterarder : " Much draining, and waste 
land reclaimed; climate good." Muckhart: "Great improvement in 
agriculture ; ague formerly prevalent, not so now." Muthill : " Healthy ; 
much draining and cultivation extended." And similar statements are 
made from the rural districts in all parts of the country. 

Ague is the most remarkable disease engendered by a marshy state of 



FEVER. 53 

the country, and consequently the disappearance of ague forms the most 
easily noted and most striking change in the health of the inhabitants 
produced by drainage ; hence ague is so often mentioned in the above 
extract. There is no doubt, however, that drainage not merely removes 
ague, but is beneficial to the public health, in removing various other 
maladies and derangements of the health which are observable among the 
inhabitants of marshy districts ; and the remark made with respect to 
Abernyte, " since the land was drained, scrofula rare" was no doubt 
founded on accurate observation. 

Numerous other statements, corroborative of the preceding, might be 
easily brought forward, but though ready to allow the general improve- 
ment in the health of the public resulting from drainage, improved habits 
of cleanliness and increased comforts, yet I cannot admit that in Ireland 
we are to expect any notable diminution of continued fever from the 
operation of these causes. In making this statement, you are aware that 
I am opposing the usually prevalent opinion. The grounds for my dissent 
have been partly explained to you already, for according to my observa- 
tion, the increase or diminution of fever in Ireland arises from some 
unknown general atmospheric, or, if you will, climatic influences, quite 
independent of locality ; and, consequently, the most improved and 
thoroughly drained towns and country districts are quite as liable to 
epidemics of typhus as are the most neglected and marshy parts of our 
island. The causes which occasion these epidemics are, on the other hand, 
in no way connected with notable variations in the seasons, for with us 
the ravages of typhus are observed sometimes in dry, sometimes in rainy 
seasons, and its epidemics appear quite uninfluenced either by the cold of 
winter or the heat of summer. Other complaints are obviously dependent 
on the physical characters of the seasons, and I have made the curious 
observation, that whenever the weather in Dublin becomes dry and steady, 
the public becomes unhealthy. This singular fact admits, perhaps, of 
explanation ; for so habituated is the Irish constitution to rapid changes 
of temperature, wind and rain, that it is placed, as it were, in an unac- 
customed, and therefore unnatural position, when the weather is dry and 
steady. Be this as it may, the fact is undoubted, that fever is neither so 
prevalent nor so fatal in any of the western kingdoms of Europe as in 
Ireland. This opinion has been long entertained by physicians, and its 
truth will appear from the following statistical report of the Census Com- 
mittee for the Province of Leinster, for the last ten years — a truly valuable 
document, now for the first time published, and for which I am indebted 
to the kindness of Doctor Wilde, the distinguished Ophthalmic Surgeon, 
under whose able superintendence the Census Committee has been placed 
by government. 



54 



ON CLINICAL INSTRUCTION. 



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From this document it follows that the mortality from fever in Leinster 
amounts to a fraction less than one-tenth of the whole mortality, whereas 
in London the fever deaths do not amount to more than one-fiftieth of the 
total deaths. This difference becomes more striking from considering that 
deaths in Dublin from fever are actually nearly double the deaths from the 
same cause in London. The last census made the population of London 
amount, I believe, to one million and a half, while that of Dublin is three 
hundred and sixty-two thousand. 

The admirable papers of Dr. Cowan have thrown much light upon the 
comparative frequency of fever in different parts of Britain, and his tables 
prove that Glasgow is more unfavourably situated, as regards fever, even 
than Dublin ; for in 1835, 1836, 1837, the deaths from fever alone were 



FEVER. 55 

412, 841, 2,180, being, in the relation to the modality from all diseases, 
one in 15*6, 10, and 4*7 annually : but as the year 1837 was remarkable 
for a fearful epidemic, this mortality is over the average, for Dr. Cowan 
in another place shows, that while in Glasgow, with a population of 
200,000, the annnal average of fever, deduced from seven years, ending 
with 1836, has been 1842 cases; in Manchester, with a population of 
228,000, it has been for the same period only 497 ; in Leeds, with a 
population of 123,000, only 274 ; and in Newcastle, with a population 
of 58,000, so little as 39. These numbers bring out, in striking contrast 
with Ireland, the immunity from fever enjoyed by large English towns, 
and corroborate the remark already made, that the eastern and central 
parts of Britain, enjoying a climate more different from that of Ireland, so 
likewise are much freer from fever than the western parts of Britain, whose 
climate approximates more to the Irish. It is curious that in those towns 
in England which have greater intercourse with Ireland, as Liverpool, 
Manchester, Bristol, typhus predominates more than others not similarly 
circumstanced. It was on this account that Dr. Lombard* concluded 
that maculated typhus fever was imported into England and Scotland by 
Irish labourers, who go over in such numbers every year to reap the 
harvest. But from the statistical reports of Dr. Cowan and others, it 
appears that, as regards Scotland, this explanation is any thing but satis- 
factory, and it seems more probable that the west of England, Scotland, 
and Ireland, in which the climate is almost the same, possess the same 
combinations of circumstances which produce typhus. Nothing, indeed, 
can be more remarkable than the facility with which a simple cold (which 
in England would be perfectly devoid of danger) runs into maculated 
fever in Ireland, and that, too, under circumstances quite free from even the 
suspicion of contagion — in truth, except when fever is epidemic, catching 
cold is its most usual cause. Much has been said and written about 
epidemics among cattle being simultaneous with human epidemics, and 
we have the testimonies of Homer and Herodotus in support of the popular 
belief. I am qiite sure that various diseases, such as ague, remittent and 
bilious fever, &c. &c, may be brought on by miasmata, which, emanating 
from the earth, may likewise produce epidemics among cattle. Mr. 
Chadwick's work contains the following: striking statement: — 

" In the course of inquiries as to what have been the effects of land 
drainage upon health, one frequent piece of information received has been 
that the rural population had not observed the effects on their own health, 
but they had marked the effects of drainage on the health and improve- 
ment of the stock. Thus the less frequent losses of stock from epidemics 
are beginning to be perceived as accompanying the benefits of drainage 
in addition to those of increased vegetable production." 

Dr. Edward Harrison, in a paper in which he points out the connection 
between the rot in sheep and other animals, and some important disorders 
in the human constitution, observes : — 

u The connection between humidity and the rot is universally admitted, 
by experienced graziers; and it is a matter of observation, that since the 
brooks and rivulets in the county of Lincoln have been better managed, 
and the system of laying ground dry, by open ditches and under-draining, 
has been more judiciously practised, the rot is become far less prevalent. 

* Dublin Medical Journal, vol. x. 



56 ON CLINICAL INSTRUCTION. 

Sir John Pringle informs us, that persons have maintained themselves in 
good health, during sickly seasons, by inhabiting the upper stories of their 
houses ; and I have reason to believe that, merely by confining sheep on 
high grounds through the night, they have escaped the rot." 

" The late Mr. Bakewell was of opinion that, after May-day, he could 
communicate the rot at pleasure, by flooding, and afterwards stocking his 
closes, while they were drenched and saturated with moisture." 

The sanatary effects of road-cleansing, to which house-drainage and 
road-drainage are auxiliary, it appears is not confined to the streets in 
towns and the roads in villages, but extends over the roads at a distance 
from habitations on which there is traffic. Dr. Harrison, whose-testimony 
has been cited on the subject of the analogy of the diseases of animals to 
those which affect the human constitution, in treating of the prevention of 
fever or the rot among sheep, warns the shepherd that, if after providing 
drained pasture and avoiding " rotting-places" in the fields, all his care 
may be frustrated if he do not avoid, with equal care, leading the sheep 
over wet and miry roads with stagnant ditches, which are as pernicious 
as the places in the fields designated as " rotting-places." He is solicit- 
ous to impress the fact, that the rot, i. e. the typhus fever, has been con- 
tracted in ten minutes, that sheep can at " any time be tainted in a quar- 
ter of an hour, while the land retains its moisture and the weather is hot 
and sultry." He gives the following instance, amongst others, of the 
danger of traversing badly-drained roads. " A gentleman removed ninety 
sheep from a considerable distance to his own residence. On coming 
near to a bridge which is thrown over the Barling's river, one of the drove 
fell into a ditch and fractured its leg. The shepherd immediately took it 
in his arms to a neighbouring house and set the limb. During this time, 
which did not occupy more than one hour, the remainder were left to 
graze in the ditches and lane. The flock were then driven home, and a 
month afterwards the other sheep joined its companions. The shepherd 
soon discovered that all had contracted the rot except the lame sheep ; 
and as they were never separated on any other occasion, it is reasonable to 
conclude that the disorder was acquired by feeding in the road and ditch 
bottoms." The precautions applicable to the sheep and cattle will be deemed 
equally applicable to the labouring population who traverse such roads. 

With reference to this question I may remark, that although I have 
carefully watched the progress of fever in Ireland for more than quarter of 
a century, I have not been able distinctly to connect its epidemics with 
any epizootic disease, — true it is, that occasionally typhus fever is prevalent 
at a time that some fatal epidemic affects horned cattle, pigs, and sheep, and 
from such an occurrence an incautious reasoner might be led to assume a 
natural connexion between the two epidemics as both proceeding from 
one cause ; a more protracted series of observations will, however, dispel 
this illusion, for he will then see that the connexion is only accidental — 
of this the years 1841 and 1842, afforded a remarkable example ; for dur- 
ing both, the cattle of Ireland were decimated by a most malignant epi- 
zootic, while during the same period I never recollect a greater immunity 
from typhus ; in fact, the wards of the Meath Hospital were often destitute 
of a single specimen of that disease. 

I have already stated that when a person gets a feverish cold in Ireland, 
it is more apt to pass into continued fever than it is in England ; this is 
especially the case when fever prevails as an epidemic, in which case the 



FEVER. 57 

transition into fever takes place on account of one or other of the follow- 
ing causes : First — the patient had been exposed to contagion, whose 
effects might never have become perceptible, had not his constitution been 
assailed by the feverish cold. Secondly ; in many cases there has been 
no previous exposure to contagion, and yet a feverish cold will finally 
determine the breaking out of fever, no doubt under the action of the pre- 
vailing epidemic influence. Thirdly, individuals who are debilitated by 
excesses, night watching, and bodily fatigue, are of all others the most 
liable to slide from feverish cold into fever; if in addition to these causes, 
mental anxiety, or intellectual labour have been harassing the individual, 
the fever generally assumes a most dangerous form, being attended with 
want of sleep, raving, and early, often violent delirium. 

The well-known fact that several had sickened on the spot on smelling 
the effluvia from a patient's person or evacuations, has led to the suppo- 
sition that the contagion of fever influences the system through the nerve^, 
and in support of this opinion many refer to Prussic acid, which, they say ', 
kills by its action on the nerves, and before it has been absorbed. 

Another class of inquirers assert that the blood is the seat of the first 
morbid change, and with equal confidence refer to the action of vegetable 
poisons, which they assert never produce any effect on the system, until 
they enter the circulation.* In the present state of our knowledge it is 
quite impossible to determine in what manner the poison acts, and, hap- 
pily, it is equally unimportant. This much is certain, that changes in 
the nature of the secretions, as in the sweat, sputa, mucus of the tongue, 
feces, and urine, take place simultaneously with changes in the blood, and 
they are all the result of some common unknown cause. Of course once 
the blood is changed, the secretions become more rapidly altered, and 
when the secretions are changed, the blood is more quickly deteriorated ; 
but the knowledge we thus obtain leads to no satisfactory explanation or 
practical result. 

Lately the investigations of chemists respecting the composition of the 
blood in fever and other diseases, have excited hopes that we are on the 
eve of discovering some more secure basis for our practice, founded on 
the analysis of that fluid. I must confess, that however I applaud these 
efforts of science, I entertain no hopes that they will be followed by the 
expected beneficial consequences ; tor, except the good effected in dia- 
betes mellitus, by diminishing the quantity of starch in the bread such 
patients eat, and the advantage derived from medicines and articles of 
diet, in certain derangements of the urinary functions, such as the phos- 
phatic and lithic diatheses ; except in these instances, I know of no im- 
provement in practice for which we are indebted to chemistry ; and even 
here the result was obtained not by an examination of living, but of 
secreted fluids ; and, in truth, it is vain to look for remedies founded on 
chemical principles, when these principles cannot even approximate to 
affording us an explanation of the mode of action of our best established 
medicines. When chemistry reveals why tartar emetic vomits, jalap 
purges, or opium causes sleep — when chemistry detects palpable changes 
in the blood produced by these remedies — then we may begin to hope 
that this science can conduct us still further, and may even, by disclosing 
the morbid changes which the blood undergoes in disease, become useful 

* Blake's Experiments, Baley's Elements of Physiology, vol. i., page 246, quoted by Dr. 
Hudson, vide " .Med. Chir. Review," April, 1841. 



53 ON CLINICAL INSTRUCTION. 

to us in searching for remedies capable of counteracting and even prevent- 
ing these changes. 

The different theories of fever, as they have been called, have much and 
often injuriously affected practice. The speculations of Brown, Cullen, 
Clutterbuck, Broussais, Rasori, Armstrong, and our Indian physicians, 
have successively introduced the stimulant, diaphoretic, general antiphlo- 
gistic, leeching, tartar emetic, mercurial plans, each of which has in its 
turn been pushed to a most deleterious excess. For my own part, I have 
long abandoned every hope of being able to frame any satisfactory theory 
of fever, and confine myself altogether to a diligent study of its symptoms, 
watching how they are grouped, and in what order they follow each other, 
and observing closely the effects of treatment on their progress ; and in 
my choice of remedies I am guided either by experience, or an analogy 
derived from the action of medicines, in other diseases which present the 
greatest similarity to the complications that occur in fever. 

Fever in this island exhibits a great variety of character, and even 
during the same epidemic remarkable differences are observable, as ap- 
pears from the subjoined summary, taken from Cheyne and Barker's valua- 
ble work on fever — vol. i., p. 431 : — 

" Delirium ferox was observed in Limerick, and other'symptoms indi- 
cating a determination of blood to the head, namely, hemorrhage from the 
nose, which, in some instances, took place to a very considerable extent. 

" As to the organs chiefly affected in the progress of the disease, some 
variety seemed to exist. In most instances the brain has been reported 
as the organ which suffered chiefly. In some instances, as at Ennis, the 
lungs were not all affected, during the early periods of this epidemic fever ; 
but in other places the lungs next to the brain principally suffered ; this 
was observed in Listowel. The same remark was made at Tralee, and 
Dr. Bishop observed at Kinsale, that the lungs were frequently affected in 
children. At Ennis it was noticed as a peculiarity in the fever, that pro- 
fuse perspiration occurred in its earlier stages without any relief to the 
patient ; and it was remarked at Waterford, as stated in the report at 
page 251, that copious perspiration often afforded no relief. Yellowness 
of the skin and tunica adnata of the eyes, was frequently noticed at Cork. 
The head and biliary system were more than usually affected. 

" As the disease advanced, it was observed in most or all parts of the 
province, that eruptions of different kinds, either closely allied to, or 
varieties of, those termed petechial, very generally accompanied it. In 
some instances the eruption was papular, or a motley appearance of the, 
skin, or a rash somewhat resembling the measles showed itself. At Cork, 
Dr. M. Barry remarked that in the species of fever which he termed syno- 
chus, petechia^ seldom occurred earlier than the fourth or fifth day ; but 
his observation, if it does not express it directly, at least implies that their 
occurrence was frequent. They were generally of a bright red colour, some- 
times small, at other times large. He did not consider them dangerous, 
nor find it necessary to abstain from those measures of depletion which 
were useful when high excitement prevailed. In a communication from 
Clonmel, Dr. Fitzgerald states, that petechias occurred in four cases out 
of five. At Fermoy, petechia appeared very generally among the poor. 
At Kinsale, a red rash, we believe of the kind above mentioned as re- 
sembling that of the measles, was common, and petechia? were more in- 
clined to red than brown in that neighbourhood. At Listowel, petechiae 



FEVER. 59 

were so common, that Dr. O'Connel did not see six cases of fever unat- 
tended by a petechial eruption, which often appeared early in the disease. 
The frequency of petechia was noticed also at Waterford, as well as of 
the eruption resembling measles already mentioned. The frequency of 
an eruption resembling measles was noticed at Bandon by Dr. Clarke and 
Dr. Jenkins. At Clonmel petechia were common even amongst children, 
in whose cases this eruption was not indicative of peculiar danger, but on 
the contrary, often attended a mild disease. It was observed in the 
neighbourhood of Tramore, and we believe the same to have happened 
in every part of Ireland, that one member of a family had petechia and 
aggravated symptoms of typhus, whilst the relatives in the same room had 
fever in the mildest form. In many instances, particularly in the more 
advanced stages of the epidemic, the lungs were observed to suffer, as at 
Fermoy,Listowel, and Mallow, according to the authorities already quoted ; 
but both at Cork and at Ennis, places very remote from each other in this 
province, the lungs, at least at the commencement of its epidemic progress, 
were but rarely affected in this fever. 

u As the epidemic advanced, gastric symptoms were observed, and 
mention has been already made of dysentery, which, in many parts of 
Munster, kept pace with fever. Dr. Grogan, of Limerick, remarked, that 
pains resembling those of rheumatism were common ; and he also noticed 
a symptom, which there is reason to believe was not unfrequent in most 
parts of Ireland, namely, that the tongue, which in most febrile diseases 
is white or altered in colour and other appearances, in many cases exhi- 
bited no morbid change, and remained moist and clean during a great 
part of the disease. From the same authority we learn that increased heat 
of surface, which is generally considered peculiarly characteristic of fever, 
was, in many instances at Limerick, altogether wanting ; this absence of 
the usual febrile heat is observed in the worst kinds of fever." 

Farther on, the report states that, " Dr. Milner Barry, of Cork, in his 
account of the fever in that city, relates that the disease presented itself 
under different forms, which he arranges under the following heads : — 1. 
Synochus ; 2. S. Cephalica ; 3. S. Pulmonica ; 4. S. Hepatica ; 5. S. Gas- 
trica ; 6. S. Enterica ; 7. Typhus gravior ; 8. Typhus Mitior ; 9. Febri- 
cula. From the arrangement which Dr. Barry here adopts it is evident 
that a determination to particular organs was at Cork, as at other places, 
of frequent occurrence." 

For more than twenty years I have in my lectures advocated the doctrine, 
that morbid anatomy had not served to reveal the cause of fever, which I 
looked upon to be an essential disease; or to use the words of Fordyce, 
" Fever is a disease which affects the whole system ; it affects the head, trunk, 
and extremities ; it affects the circulation, absorption, and the nervous system ; it 
affects the body, and it affects the mind; it is therefore a disease of the whole 
system, in the fullest sense of the term. It does not, however, affect the va- 
rious parts of the system uniformly and equally, but, on the contrary, some- 
times one partis more affected than another.^ " This excellent view of 
fever seems to be borne out completely by modern pathology, and parti- 
cularly the last part, where he says, that in cases of fever one part is more 
affected than another. We have, for instance, cerebral fevers, nervous, 
bilious, gastric, and catarrhal fevers, by which, it is to be observed, we do 
not mean to imply that there is nothing more than simple disease of the 
brain, or nerves, or liver, or bowels, or respiratory system, but that in each 



60 ON CLINICAL INSTRUCTION. 

of these fevers disease predominates in some particular part. So that when 
we speak of these fevers, we speak of such a fever as Fordyce has de- 
scribed, in which one part of the body is affected more than the rest."* 

I am happy to find that the views I have so long entertained in oppo- 
sition to the great majority of writers both in Britain and on the Conti- 
nent, are now generally acknowledged to be correct, as will appear by 
the following passage taken from the able essay on continued fever by Dr. 
Christison in the " Library of Medicine." 

11 Anatomical characters of continued fever. — The pathological anatomy of 
continued fever remained, until lately, in a very crude and unsatisfactory 
condition. But no other topic has attracted so much attention during the 
last five-and-twenty years, or has been investigated with more success, so 
far as the accumulation of facts goes. Whether the result has been hitherto 
beneficial in reference either to pathological doctrine or medical practice, 
is a question which admits of some doubt. A very great variety of mor- 
bid appearances have been indicated as occurring in fever. Of these 
many are plainly incidental, because they do not by any means present 
themselves regularly, others, however, have been held to be invariable ; 
and consequently authors have sought for the nature and essence of fever, 
in the local morbid action which gives rise to such appearances. On 
taking into account the general result of the observations of all patholo- 
gists of credit, it seems impossible to avoid the conclusions, that no mor- 
bid appearance is invariable except congestion of internal organs ; that 
every other pathological fact which has been observed is not constant and 
is therefore the effect of a secondary disease ; and that, in all the obser- 
vations hitherto made on the pathological anatomy of fever, we must be 
content with discovering its consequences, not its causes. The information 
which has been amassed is important in a practical point of view, as turn- 
ing the attention of practitioners to the necessity of studying and treating 
these secondary affections, which in various circumstances are the occa- 
sion of suffering, danger or death. But it does not seem to throw much 
light on the real essence of fever, and by being rashly assumed to furnish 
that light, it has led to grave, theoretical and practical, errors." 

In fact, gentlemen, the knowledge we possess of the pathology of typhus 
fever, is of a negative character. Pathology teaches us what typhus is not, 
rather than what it is ; it shows us that it is neither cerebritis, meningitis, 
pneumonia, pleurisy, gastritis, or enteritis, for it may exist without any of 
these, and they may exist without typhus fever ; but it also shows that one 
or other of these lesions frequently arises in the course of that fever, and 
these require special attention. 

It is difficult to classify the different varieties of fever that are observed 
in this city. The following are the most remarkable of the distinct varie- 
ties that have come under my notice : — 

1st, Simple continued fever, without maculae, or any notable determi- 
nation to particular organs. 2d, Continued fever, without maculae, with 
determination to some organ. 3d, Continued fever, with maculae. 4th, 
Continued fever, accompanied fromtkevery beginning with gastric derange- 
ment, and epigastric tenderness. 5th, The last-mentioned species, but 
in a more intense form, having black vomit and yellowness of the skin 
superadded. 6th, Continued fever, with petechiae. 

* Stokes's Practice of Physic (American Edition, page 409). 



FEVER. 61 

I have observed each of these varieties of fever constituting epidemics, 
which lasted for longer or shorter periods ; but with us the dominant type 
of epidemics is the maculated. This species, too, confers more immu- 
nity upon the sufferers than any variety of fever, and in this respect, as 
well as in its well-marked eruption, it approaches in character to the 
exanthemata ; like the exanthemata, too, this species of fever seems to 
be the most contagious. 

Concerning contagion, the physicians of Ireland and Scotland are 
nearly agreed in attributing that quality to fever. The fever wards of the 
Meath Hospital are by no means crowded, and are both well ventilated 
and cleanly, while the building itself is placed in the most salubrious 
part of the vicinity of Dublin, being built upon the site of Dean Swift's 
garden ; and yet it almost invariably happens, that when a patient, 
labouring under any other acute disease, or any chronic disease, is admit- 
ted into a fever w T ard, he gets fever in the course of a fortnight, or even 
sooner. This happens the more surely if the patient is placed in the 
immediate vicinity of a maculated case. Among the pupils who attend 
the hospital, the greater number are sooner or later attacked by fever ; 
and the same is true of the porters, laundry-maids, and nurses. 

I have great pleasure in recommending Dr. Christison's observations 
on this subject, and shall here quote briefly some of the arguments ad- 
vanced by him in support of the contagious nature of the disease. In 
the first place he says, that in districts thinly inhabited, fever is generally 
very rare, whereas in large towns, where numbers of people are living in 
a crowded state, typhus fever is never absent. When it becomes epi- 
demic in a large town, it never bursts forth with impetuosity, like the 
diseases of undoubted miasmatic origin; but extends gradually, and always 
the more slowly the larger the city, so that many months may elapse be- 
fore it reaches its full height. It then begins to decline, retires as gradu- 
ally as it commenced, and finally resumes its natural condition, affecting 
only a few individuals here and there, and at distant intervals. 

At the commencement of an epidemic, fever is found to spread at first, 
not by scattered unconnected cases occurring at a distance from one an- 
other, but by slow degrees around one or more invalid localities as foci ; 
first creeping from one. individual to another of a family, then from family 
to family, according to their proximity, relationship, or general intercourse, 
and at length to the surrounding population promiscuously. 

But a further argument of very great weight may be drawn even from 
the very violations of this general rule. For sometimes the disea.-e is seen 
suddenly to arise, and gradually to spread in parts of a town where it had 
not previously existed ; and this in concurrence with the arrival of the 
disease by importation from a previously invaded locality. 

u Another argument, more powerful perhaps than any other, and upon 
which alone the doctrine of the communicability (Dr. C. uses this word in 
preference to contagion or infection) of fever might be rested, is, that 
in circumscribed localities, inhabited by crowded bodies of men, fever 
is observed invariably to spread among the healthy, when it is introduced 
to a great extent from without, but never materially at any other time. 
This is a general mode of expressing the history of such institutions 
as infirmaries and fever hospitals. During the last twenty years the 
Infirmary of Edinburgh has been the receptacle of a large proportion 
of fever cases in three epidemics, which have lasted between three and 



62 ON CLINICAL INSTRUCTION. 

four years ; and there have been two intervals varying from three to five 
years in duration. During the intervals, when fever cases from without 
were few, fevers originating within the hospital were extremely rare 
among any classes of individuals attached to its service. But during the 
prevalence of the several epidemics fever abounded in every department 
of its service : physicians, clinical clerks, general servants, nurses, washer- 
women, apothecary's assistants, all suffered more or less, and some to an 
excessive degree. The same facts were observed even more remarkably 
in an institution which was, during the same interval, occasionally occu- 
pied as a fever hospital. In these epidemics it was made use of for this 
purpose ; and at various periods during the last twenty-five years, it has 
also been occupied, w T hen fever did not prevail epidemically in the city, 
by crowded bodies of men, first by soldiers as a barrack, then as a retreat 
for some hundreds of poor people, who were turned out of their houses in 
winter by an extensive fire, next as a quarantine house during the preva- 
lence of cholera, and for some years past, during the worst epidemic of 
fever which has yet prevailed in the city, it has been occupied by about 
300 of the very lowest of the community, namely, as a house of refuge 
for vagrants and other persons. Now, on each occasion, when it was 
occupied as a fever hospital, the people on service in the institution suf- 
fered to an extraordinary degree, scarcely a single individual escaping an 
attack, w T ho remained a moderate length of time in it. But on other 
occasions, fever was either absolutely unknown, or the cases were rare 
and distant, and easily referable to the particular manner of life of the 
individuals composing the population of the establishment. It is also 
worthy of notice, in reference to both chains of facts here mentioned, that 
neither around the infirmary, nor around the late fever hospital, did fever 
ever prevail to any material extent during any of its epidemic visitations." 
It is unnecessary to allude to the many instances of fever occurringamongst 
nurses, porters, and clinical clerks in different fever hospitals, which 
strongly bear out the view that typhus fever is eminently contagious. 

Another interesting point connected with the contagion of fever has 
lately been inquired into, viz., to determine the particular period of the 
disease when this character is most remarkable. 

Dr. Perry, of Glasgow, was the first, I believe, who advanced the opi- 
nion that the stage of convalescence was the most infectious in typhus 
fever. He considers typhus fever as a true exanthema. He says, " I 
have some years entertained the opinion, founded upon an extensive 
series of observations, that contagious typhus is an exanthematous disease, 
and is subject to all the laws of the other exanthemata ; that, as a general 
rule, it is only taken once in a life-time, and that a second attack of typhus 
does not occur more frequently than a second attack of small-pox, and 
judging from my own experience, less frequently than a second attack of 
measles or scarlet fever." 

From numerous observations and experiments I am satisfied, that it is 
not contagious before the ninth day, perhaps not till after a later period of 
the disease. Among many circumstances which establish this opinion, I 
may mention one experiment which I made upon a pretty extensive scale. 
The fever wards of the Glasgow Royal Infirmary are each capable of con- 
taining twenty patients. The beds are arranged in two opposite rows, 
and are pretty near each other. While the patients are in the acute wards, 
they are not allowed the use of their clothes, though they may be able to 



FEVER. 63 

sit up ; they are, therefore, almost constantly confined to bed, except when 
rising to stool ; and there is about one close stool to every three patients. 
Into the fever-house are admitted cases of measles, scarlet fever, and small- 
pox : and patients are very frequently sent in labouring under bronchitis, 
pneumonia, erysipelas, and other local inflammatory affections. I found 
by experience, that when the latter class of patients were sent to the con- 
valescent ward, where they necessarily mixed with the others, almost all 
of those who had not a previous attack of typhus fever were either seized 
with it before leaving the house, or returned soon after their dismissal 
labouring under it ; the period intervening between the time of their being 
sent to the convalescent ward, and the attack, never being less than eight 
days. Although means were taken to keep those recovering from small- 
pox, scarlatina, &c, in a separate room from those convalescent from 
typhus, the rooms being adjoining the non-intercourse was incomplete, 
and the result was, that these diseases occasionally spread among the 
typhus convalescents, and the convalescents from small-pox and scarla- 
tina caught typhus. In consequence of these observations, I adopted the 
practice of not sending, as formerly, to the convalescent wards, those 
patients affected with inflammatory diseases, unless I ascertained that 
they were secured against the disease by having had a previous attack of 
typhus ; but kept them in the acute fever wards till they were so far 
recovered as to go to their own houses, and the result was (and the prac- 
tice w T as continued for several months), that not one of those detained in 
the acute wards caught the disease while there, or returned with it after- 
wards. From the above and other observations, I have adopted the opi- 
nion, that typhus, like measles, small-pox, &c, is chiefly spread during 
the period of convalescence. In the paper already noticed, I have men- 
tioned the desquamation of the cuticle, which usually takes place when a 
patient is convalescent from typhus. Do the fine scales thrown off in this 
state contain the poison which, by adhering to the clothes and hair of the 
patient, are carried about with him, and being rubbed off are, while float- 
ing in the atmosphere, applied to the mucous surface, or inhaled by a sus- 
ceptible recipient, in whom it produces, after a certain time, the specific 
disease ?* 

1 shall now, in pursuance of my intention, proceed to speak of the treat- 
ment of fever. I may observe here, that we are now at a point of time 
possessing no common interest for the reflection of medical observers.! It 
is now nearly two years since my attention was first arrested by the appear- 
ance of maculated fever, of which the first examples were observed in some 
hospital patients from the neighbourhood of Kingstown. This form of fever 
has lasted ever since, prevailing universally, as if it had banished all other 
forms of fever, and being almost the only type noticed in our wards. 
Within the last four days, however, a change appears to have taken place. 
Scarcely any cases of maculated fever have been admitted within the last 
fortnight, and the majority of fever patients at present under treatment are 
free from cutaneous eruption, so frequently observed during the last two 
years. The cases which we have recently admitted present no spots, or 
maculae, and have been termed, perhaps improperly, simple typhoid fever. 
And here permit me to observe, that it would be very wrong to conclude, 
from this circumstance, that our recent cases are of a more favourable de- 

* Dublin Medical Journal, vol. x. 

\ This lecture was delivered at the beginning of the session 1836-7. 



64 ON CLINICAL INSTRUCTION. 

scription than those which preceded them ; the disease, it is true, appears 
to have lost a character which is always looked upon as bad and unfavour- 
able, but it may be just as dangerous a modification of fever as the erup- 
tive typhus. During the predominance of the latter form, all cases with- 
out maculse were in general simple and free from danger : but it is proba- 
ble that this is not the case at present. There are two cases of this non- 
maculated typhus in the female ward, which are of an extremely doubtful 
character, and in which it would be difficult to predict the result. Indeed, 
w T ere I to make any prognosis, I should say that the chances, if not against 
them, are at least very fairly balanced. 

Now, gentlemen, as it appears we have come to a change, and that we 
may have to treat a new modification of fever, it behooves us to be ex- 
tremely vigilant. I invite you to watch and study, with the closest atten- 
tion, the cases of fever which come before you. Let us, in the first place, 
endeavour to ascertain whether we have seen the close of one epidemic, 
and are now at the commencement of another. The number of cases of 
simple typhoid fever have, you perceive, increased in a very remarkable 
manner, and the number of cases of eruptive typhus have become remark- 
ably scarce. But there is another and a more important reason why we 
should study these cases with all due diligence anil attention. They may 
be the first examples of a new epidemic, and every new epidemic, as it 
has its peculiar characters, so has it its peculiar treatment. We cannot fol- 
low the same track which we have pursued for the last two years — we 
cannot apply our remedies with the confidence of experience — we must 
now strike into a new path, and for some time our practice must be ten- 
tative and experimental. It was only after a good deal of experimental 
observation that we were able to arrive at a plan of treatment adapted to 
meet the exigencies of the maculated form of fever : and it is very probable 
that this new fever may prove at first extremely difficult to manage ; and 
it maybe some time before the diminished rate of mortality will show that 
we have at length discovered its true character, and the remedies best cal- 
culated to arrest its progress. 

Let me now direct your attention to some practical points connected 
with the treatment of the maculated fever which has prevailed for the last 
two years, and which has spread to a very considerable extent in this city 
and its environs, attacking alike the upper, middle, and lower classes of 
society. It is not ray intention to enter into a detailed history of the origin 
and progress of this fever, its varieties, symptoms, and pathological pheno- 
mena ; my purpose is to furnish you with a brief but comprehensive out- 
line of its treatment, and of the remedies which have been found most suc- 
cessful in its removal, as well as the most appropriate time and mode of 
their application. 

Having made these general observations, I may observe, in addition, 
that in the whole range of human maladies there is no disease of such sur- 
passing interest and importance as fever ; and I cannot dwell too much on 
the necessity of your applying most attentively to the study of its pathology 
and treatment. If you compare the mortality from fever with that result- 
ing from any other disease in this country, you will be struck with the 
overwhelming fatality of this affection, and will readily admit the inesti- 
mable value of a thorough knowledge of its nature and treatment. Re- 
collect, too, that fever is a disease which numbers among its victims per- 
sons chiefly in the prime of life, and during the most active and useful 



FEVER. 65 

stage of existence, — fathers and mothers, persons who are the ornament or 
the stay and support of their families, the intellectual, the industrious, the 
efficient, — those whose lives are most valuable to their friends and to so- 
ciety. This gives an additional interest to the study of fever, and should 
stimulate you to endeavour to arrive at a correct knowledge of its nature 
and treatment. And here let me observe, that there is nothing more un- 
true than the assertion, that the treatment of fever is a matter of indiffe- 
rence. It has been the custom to look upon every plan of treating fever 
as idle and absurd, and until very lately there were many persons in this 
country who believed that patients recovered not from having had the ad- 
vantage of treatment, but from goodness of constitution or some favourable 
accident ; and it was usual with such persons to appeal to the experience 
of Dr. Rutty, who, in recording the history of the epidemics of his own time 
(1741), observes, " the poor abandoned to the use of whey and God's good 
providence recovered, while those who had generous cordials and great 
plenty of sack, perished." And, indeed, I must admit that the treatment 
of some of the cases of fever which I witnessed when a student, would 
seem to justify the quaint and sarcastic observation of Dr. Rutty. At that 
period, whether it was from bad treatment, or from what has been termed 
the nimia diligentia medici, it is a fact that the maximum of mortality was 
among the rich, and that those who were most attended to, died most 
speedily. In the epidemics of 1816, 1817, 1818, and 1819, it was found 
by accurate computation, that the rate of mortality was much higher among 
the rich than among the poor.* This was a startling fact, and a thousand 
different explanations of it were given at the time; but I am inclined to 
think that the true explanation was, that the poor did not get so much 
medicine, and that in them the vis medicatrix had more fair play.f I could 
appeal to the practice of those times in proof of this opinion, and as we go 
along I shall have an opportunity of alluding to this part of the subject 
again, and contrasting the practice of the present day with that which was 
generally followed thirty years ago. If you look to Dr. Cheyne and Dr. 
Barker's Synopsis of the plan of treatment employed by the physicians of 
those days, you will be prepared, from a mere inspection of it, to admit 
that it was at least as hard to escape the physician as the disease. Since 
that period our practice has greatly improved, and things are much 
changed ; the preponderance of fatal cases is now to be found among the 
poor, and trie mortality among the rich, or these who have proper medical 
advice from the commencement, is not one-third of that which is found 
among the indigent, who are generally neglected at the commencement 
of the disease. I am therefore fully prepared to deny that, in the present 
state of medical knowledge, our practice is a matter of indifference; on 
the contrary, there is no disease in which diligent attention and skilful 
treatment are more frequently successful than in fever, nor is there any 

* " The rich are less frequently affected with epidemic fevers than the poor,, but more fre- 
quently die of them. Good fare keeps off diseases, but increases their mortality when they 
take place." — Fletcher's Puthology, p. 27. 

\ " On the whole the mildest and simplest treatment seems to be the most generally suc- 
cessful, and the result of a certain Lady liountiful's practice forms its best com nent .iry. She 
begins with an antimonial emetic ; the patient is washed every morning with soap and water,, 
gets every second day half an ounce of sulphate of magnesia, on the seventh day a blister to 
the neck, and if necessary some diluted wine, this seldom and sparingly ; of ICO in fever, treated 
after this mechanical plan, not one died." — Cheyne and Barker s Report, p. 444. 

6 



66 ON CLINICAL INSTRUCTION. 

affection of equal importance in which our therapeutic means are more 
efficient and valuable. 

Now, when called on to treat a case of fever, there are several things 
which require your attention. In the first place, you should examine the 
state of the family arrangements. This is a matter which men are apt to 
overlook or treat as a matter of indifference, but in my mind it is of no ordi- 
nary importance, and should always be attended to. You should never, if 
possible, undertake the treatment of a case of fever where the friends or re- 
lations of the patient supply the place of a regular fever nurse. The mis- 
taken tenderness of relatives, and their want of due firmness, presence of 
mind, and experience, will frequently counteract your exertions and mar 
your best efforts. Affection and sorrow cloud the judgment, and hence it 
is that very few medical men ever undertake the treatment of dangerous 
illness in the members of their own families. The sympathy which a nurse 
should have for her patient should be grounded on a general anxiety to 
serve, and a strict sense of duty, as well as a laudable desire of increasing 
her own reputation ; it is, in fact, a sympathy analogous to that which 
should actuate a physician. Again, it will not do to have a nurse who 
has been usually employed in other diseases ; your assistant must be a 
regular fever nurse, and the man who undertakes the treatment of a long 
and dangerous case of fever without such an assistant, will often have cause 
to regret it. I could mention to you many cases illustrative of the truth 
of this assertion. I could tell you,* that where I have permitted the con- 
tinuance of the services of one of the family, or of a common nurse, I have 
been almost invariably annoyed and disappointed. I now T make it a general 
orule to refuse attending any dangerous and protracted case of fever with- 
out a properly qualified nurse. 

In the next place, when treating a case of bad typhus, do not think that 
it will be sufficient to see your patient once a-day. But you will say, 
perhaps, that our hospital patients here do very well, and yet they are 
visited only once in the twenty-four hours. True — but then we have 
experienced nurses to look after them at all hours ; we have the valuable 
surveillance of our apothecary, Mr. Parr; we have the attendance of the 
resident pupils, and of the gentlemen who take charge of the cases. You 
see then that they do not depend on a solitary visit. How often has Mr. 
Parr, or the resident pupil, found it necessary to change the treatment 
adopted at the morning visit ? How often have the remedies of which we 
had only given a hint in the morning, been actively and energetically 
employed before the close of the day ; and how often have lives been 
saved by the valuable attentions to which I have just alluded ? No one 
should attend a case of fever without having proper medical assistants. 
My practice, in general, is to visit my fever patients tw T o or three times a- 
day ; and, when I have a bad or a dangerous case to manage, I always 
have a competent medical assistant to stay by the patient and watch every 
change of his malady. I do not know how they manage this matter else- 
where, but in this city we have so many zealous, intelligent students, so 
many young medical friends, and so many well-educated apothecaries, 
that we are never at a loss for an assistant. This fact is, I think, a sufficient 
answer to the objections put forward by Dr. Johnson, in the last number 
of the Medico-Chirurgical Review. He says that tartar emetic is a two- 
edged sword — an agent powerful alike for good or evil, and in the admin- 
istration of which no ordinary circumspection is demanded. All this 1 



FEVER. 67 

am willing to admit ; there is no remedy capable of producing more mis- 
chief when abused, but when properly watched it is, I am confident, the 
means of saving many valuable lives. He says, also, that Dr. Graves 
cannot give that share of attention to his patients which the employment 
of such a remedy demands. He is quite mistaken on this point. I am 
never at a loss for some skilful person to remain with the patient, watch 
the operation of each dose, arid modify or change it according to circum- 
stances. The want of proper assistants may be elsewhere an objection to 
the administration of tartar emetic, but this objection does not hold good 
with respect to Dublin. 

One or two more observations of a general nature. Some persons have 
such a terror of foul air, in cases of fever, that you will find all the windows 
in the house thrown open, not even excepting those of the patient's bed- 
chamber, and wherever you turn you are sure to meet with a current of 
air. Now, this is an unnecessary practice, likely to entail disease on 
the family and local inflammation on the patient. The bed-room of a 
patient labouring under fever should be well aired, but without what is 
termed thorough air ; and it should, if possible, be a quiet back room, 
away from the street. In the next place, it should be sufficiently large 
to hold two bedsteads conveniently ; and you should order the attend- 
ants to have two well-aired beds in readiness, from one of which the 
patient should be changed to the other every twelve or twenty-four 
hours. You can scarcely have an idea of the comfort this affords to a 
person in fever. The room can be kept properly ventilated by a fire, and 
the temperature can be regulated by a thermometer. Some persons are 
in the habit of constantly sprinkling the room with vinegar — others with 
the chlorides. I do not know that it is necessary, and I think the use 
of chlorine is doubtful, if not improper, and may prove injurious to the 
patient. 

Having made these few general observations on the steps to be taken 
by those who enter on the treatment of typhus, I shall now proceed to 
speak of diet and medicines. In a disease like fever, which lasts fre- 
quently for fourteen, twenty-one, or more days, the consideration of diet 
and nutriment is a matter of importance, and I am persuaded that this is 
a point on which much error has prevailed. I am convinced that the 
starving system has, in many instances, been carried to a dangerous excess, 
and that many persons have fallen victims to prolonged abstinence in 
fever. This was one of the errors which sprung from the doctrines of 
those who maintained that fever depended on general or topical inflam- 
mation. They supposed that fever arose from inflammation, and imme- 
diately concluded that, to treat it successfully, it was necessary to reduce 
the system by depletion and low diet, and to keep it at this point during 
the whole course of the disease. Hence the strict regimen — the diete 
ahsolue — of the disciples of the physiological school, and of those w T ho 
looked on inflammation as the essence of fever. The more the symptoms 
appeared indicative of inflammatory action, the more rigorous was the 
abstinence enforced. If a patient's face was flushed, or his eyes suffused, 
no matter what the stage of the fever was, they said, " here is inflamma- 
tion of the brain, and nourishment will exasperate it." If he had red or 
dry tongue, and abdominal tenderness, they immediately inferred the 
existence of gastro-enteritis, and all kinds of food, even the lightest, were 
strictly forbidden. That this proceeds from false notions on the nature of 



68 ON CLINICAL INSTRUCTION. 

fever is beyond doubt, and I pointed out this fact many years ago, long 
before the appearance of Piorry's work. Let us, in the first place, examine 
the results of protracted abstinence in the healthy state of the system. 
Take a healthy person and deprive him of food, and what is the conse- 
quence ? First, hunger, which after some time goes away, and then 
returns again. After two or three days the sensation assumes a morbid 
character, and instead of being a simple feeling of want and a desire for 
food, it becomes a disordered craving, attended with dragging pain in 
the stomach, burning thirst, and some time afterwards, epigastric tender- 
ness, fever and delirium. Here we have the supervention of gastric 
disease, and inflammation of the brain as the results of protracted starva- 
tion. Now, these are in themselves very singular facts, and well deserv- 
ing of being held in memory. Read the accounts of those who perished 
from starvation after the wreck of the Medusa and the Alceste, and you 
will be struck with the horrible consequences of protracted hunger. You 
will find that most of the unhappy sufferers were raging maniacs, and ex- 
hibited symptoms of violent cerebral irritation. Now, in a patient labouring 
under the effects of fever and protracted abstinence — whose sensibilities 
are blunted, and whose functions are deranged — it is not at all improbable 
that such a person, perhaps also suffering from delirium or' stupor, will not 
call for food, though requiring it ; and that if you do not press it on him, 
and give it as medicine, symptoms like those which arise from starvation 
in the healthy subject may supervene, and you may have gastro-enteric 
inflammation, or cerebral disease, as the consequence of protracted absti- 
nence. You may, perhaps, think that it is unnecessary to give food, as 
the patient appears to have no appetite and does not care for it. You 
might as well think of allowing the urine to accumulate in the bladder, 
because the patient feels no desire to pass it. You are called on to inter- 
fere where the sensibility is impaired, and the natural appetite is dormant ; 
and you are not to permit your patient to encounter the horrible conse- 
quences of inanition, because he does not ask for nutriment. I never do 
so. After the third or fourth day of fever, I always prescribe mild 
nourishment, and this is steadily and perseveringly continued through the 
whole course of the disease.* 

* In the preceding lecture frequent mention has been made of petechial fevers, particularly 
in the passage cited from (Jheyne and Barker's work, respecting the fever of 1816 and J8J7 ; 
and, in compliance with the generally received opinions, 1 have set down this fever as a dis- 
tinct species. I must acknowledge, however, that I myself have never seen petechial fever 
epidemic in Ireland. I was clinical clerk at Sir Patrick Dun's Hospital during the great epi- 
demic of 1816 and 1817. The eruption consisted of macula?, somewhat resembling measles, 
frequently dark and livid in bad cases ; but except in a very few instances indeed there were 
no true petechia?. In 1822 I had the charge of a large district, in the town of Galway, when 
fever was committing great ravages ; then too the eruption was maculated. I cannot account 
for so many witnesses testifying the contrary to this statement, except by supposing them to 
have been misled by appearances ; for it must be confessed that although true petechias are 
rare, true jlea-bites are common in Ireland. Most observers, too, seem to have been very inac- 
curate in their phraseology, as is evident from the above quotation from Cheyne's work. Dr. 
Barry plainly uses the word petechias very loosely — " They ivere generally of a bright red 
colour, sometimes small, at other times large." Surely this is quite descriptive of maculae, but 
totally inapplicable to petechia ; arid the same may be said of the other observers, most of 
whom, I verily believe, overlooked the true eruption, and noted down flea-bites as petechia? ! 
Connected with the question first raised by Dr. Perry, whether maculated typhus should be 
considered as an exanthema, the fact is deserving of notice, that children exhibit the eruption 
much less frequently than adults, although they are quite as liable to the fever, when it is 
epidemic. This fact is the more remarkable, because in measles, scarlatina, &c, the true exan- 
themata, the eruption is more constant in children than in adults. 



FEVER. 69 



LECTURE V. 

General treatment of fever — Dietetic management— The starvation system may produce organic 
disease — Proper food for fever patients and convalescents — Allaying of thirst — Sedatives — 
Expergefacients — Kfficacy of green tea in a case of narcotism — Flagellation effectual in a ' 
case of poisoning with opium. 

At my last lecture I spoke of some preparatory steps which should be 
taken before you enter on the treatment of a case of fever. I stated that 
one of the most essential requisites was a good nurse ; that you can readily 
find persons to undertake this office in every family, but that it is rare to 
meet with any individual among the patient's relatives properly qualified to 
discharge so important a duty. There is a vast difference between readi- 
ness to undertake and ability to perform. Some persons are always 
a-doing, but never do right; always attempting but never successful. 
There are many nurses who are extremely attentive, but inexpert and 
injudicious, and their ill-judged attentions are frequently prejudicial to 
the patient. A fever nurse has a vast deal in her power ; if an enema is 
to be administered, the patient will be much less disturbed and annoyed 
than if it were given by an unskilful person. The mere handling of a 
patient — the moving of him from one bed to another — the simple act of 
giving him medicine or drink — the changing of his sheets and linen — the 
dressing of his blisters — and a thousand other offices, can be performed 
with advantage only by an experienced nurse. Always bear in mind that 
it is of the utmost importance to economise the patient's strength in fever. 
The very act of lifting him up, or moving him from one side to another, 
tends to produce exhaustion. In the advanced stages of fever, the services 
of a properly qualified nurse are inestimable. Then there is the moral 
management of the patient, and this is an office which no one can under- 
take unless qualified by experience, and a correct knowledge of the habits 
of persons labouring under such forms of disease. Every one admits the 
value of moral superintendence in the treatment of the insane. Now there 
are very few patients who are not in a state analogous to insanity, for a 
longer or shorter period, during a course of typhus fever. There is a 
necessity for moral management in fever as well as in insanity, and this 
is understooil only by an experienced nurse. Friends or relatives are 
seldom found capable of discharging this office. If they chance to discover 
from the physician's remarks or questions the weak points of the patient's 
case, they generally contrive to let him know them in some way or other. If 
the patient is restless, for instance, the ill-judged anxiety of his friends 
will most certainly prevent him from sleeping. They steal softly to his 
bed, draw the curtains, move the candle so as to make the light fall on 
his eye.i>, and wake him perhaps at the moment he is settling down to rest. 
If he happens to take an opiate, and that they are aware of the nature, of 
his medicine, they inform him of it, and his anxiety for sleep, conjoined 
with their inquiries, prevent its due operation. Hence, when you pre- 
scribe an opiate, you should not, in any case, say any thing about it ; and 
it should not be administered in such a way as to lead the patient or his 
friends to expect decided benefit from it. It is only where I have to deal 



70 ON CLINICAL INSTRUCTION. 

with prudent persons that I break through my rule of concealing both the 
nature of the medicine and the results which I expect from its operation. 
One of the best ways of giving an opiate is to administer it in the form of 
an enema. The patient's attention is then turned away from the consi- 
deration of loss of rest — he supposes that the enema is to act on his bowels, 
and in expecting a motion he drops asleep. You will often, too, succeed 
in producing sleep in this way, where you would fail in bringing it on by 
an opiate administered by the mouth. Another recommendation attached 
to this mode of exhibiting opiates is, that it can be employed in cases of 
delirium, where the patient obstinately refuses to swallow any kind of 
medicine. Let me give you here another caution. Do not let the patient 
know the situation or extent of his danger, however you may feel bound 
to act in reference to these matters towards his relatives or friends. If 
you apprehend mischief in the brain, do not commence by examining the 
head, or putting your questions in such a manner as to lead him to suspect 
the seat and nature of the affection. The same remark may be applied to 
the examination of the thorax and abdomen. 

At my last lecture I endeavoured to impress upon you, that persons have 
been occasionally starved to death in fever, and laid before you some re- 
markable facts connected with the influence of protracted abstinence on 
the general system, as well as on the brain and digestive tube. I endea- 
voured to show that long-continued denial or want of food generates symp- 
toms bearing a very close resemblance to those which are observed in the 
worst forms of typhus. Pain of the stomach, epigastric tenderness, thirst, 
vomiting, determination of blood to the brain, suffusion of the eyes, head- 
ache, sleeplessness, and, finally, furious delirium, are the symptoms of pro- 
tracted abstinence ; and to these we may add, tendency to putrefaction of 
the animal tissues, chiefly shown by the spontaneous occurrence of gan- 
grene of the lungs. It has been shown by M. Guislain, physician to the 
hospital for the insane, at Gand, that in many instances gangrene of the 
lungs has occurred in insane patients who have obstinately refused to take 
food. Out of thirteen patients who died of inanition, nine had gangrene 
of the lungs. You perceive, then, that starvation may give rise to symp- 
toms of gastric disease, to symptoms of cerebral derangement, and to mor- 
tification of the pulmonary tissue. It is not, therefore, wrong to suppose 
that when a system of rigorous abstinence has been observed in fever, and 
when food has been too long withheld, because, forsooth, the patient does 
not call for it, and because his natural sensibilities are blunted and im- 
paired — it is not, I say, unreasonable to infer that gastric, cerebral, and 
even pulmonary symptoms may supervene, analogous to those which re- 
sult from actual starvation.* 

An attentive consideration of the foregoing arguments has led me, in the 
treatment of long fevers, to adopt the advice of a country physician of 

* The following interesting case is very illustrative of the views advanced in the text : — 
Huxham gives the history of a gentleman " who obstinately starved himself to death, and 
would not, for many days, either by force or persuasion, swallow any kind of food, or a drop 
of liquor. He soon grew feverish, flushed in his face, and very hot in his head ; his pulse was 
small, but very quick, in four or five days his breath became exceedingly offensive, his lips dry, 
black, and parched, his teeth and mouth foul, black, and bloody, his urine vastly high-coloured 
and stinking as much as if it had been kept a month ; at length he trembled continually, could 
not stand, much less walk, raved and dozed alternately, fell into convulsive agonies frequently, 
in which he sometimes sweated pretty much about the head and breast, though his extremities 
were quite cold, pale, and shrivelled ; the sweat was of a very dark yellow colour, and of a 
most nauseous stench." 



FEVER. 71 

great shrewdness, who advised me never to let my patients die of starva- 
tion. If I have more success than others in the treatment of fever, I think 
it is owing in a great degree to the adoption of this advice. I must how- 
ever observe, that great discrimination is required in the choice of food. 
Although you will not let your patient starve, do not fall into the opposite 
extreme: you must take care not to overload the stomach. When this is 
done, gastro-enteric irritation, tympanitis, inflammation, and exasperated 
febrile action are the consequences. I have witnessed many instances of 
the danger of repletion in febrile diseases. A case of this kind occurred 
some time ago in this hospital, in a boy who was recovering from perito- 
nitis. In another case, in private practice, an incautious indulgence in 
the use of animal food was followed by a fatal result. A young lady ate 
some beefsteak, contrary to my orders, at an early period of convalescence 
from fever, relapsed almost immediately, and died of enteritis in thirty-six 
hours. Food must be given with great care and judgment, particularly 
in the beginning of fever. For the first three or four days, particularly if 
the patient is young and robust, water, weak barley-water, and whey will 
be sufficient. After this it may be well to begin with some mild nutri- 
ment. What I generally give is some well-boiled gruel, made of groats, 
and flavoured, if there be no tendency to diarrhoea, with sugar and a small 
quantity of lemon juice. The ordinary oatmeal gruel does not answer suf- 
ficiently well for this purpose, for it is apt to produce griping and diarrhoea, 
symptoms which are extremely disagreeable in the commencement of fever, 
and which often lead to others of a more troublesome and formidable cha- 
racter. I am also much in the habit of ordering a little thin panado, morn- 
ing and evening, during the latter part of the first, and the beginning of 
the middle stage of fever. A small slice of bread is slightly toasted, and 
boiling water poured on a tablespoonful of the crumbs, in sufficient quan- 
tity to make a thin panado, of which the patient takes a tablespoonful two 
or three times a-day. It may be flavoured with a very small quantity of 
lemon juice and sugar, if there is no tendency to diarrhoea; but where this 
exists, or where you are administering mercurials, I think you should be 
cautious in the use of acids. Although medical men of the present day 
do not object to giving acids during the use of mercurials, I think the 
practice is not entirely devoid of danger, and I think our predecessors 
were right in withholding them under such circumstances. You will begin, 
then, on the third, fourth, or fifth day, according to circumstances, with a 
little gruel ; and after two or three days you may add a little panado, giving, 
as I have already observed, a spoonful of either every third hour. As the 
fever advances you may add some mild animal jelly or broth; and one of 
the best kinds of nutriment in the middle and latter stages of fever, is 
chicken broth. I do not speak here of chicken water; I mean good and 
well-made chicken broth. Give this, but give it in small quantities, and 
with great caution at first. Watch the effects of the few first spoonfuls; it 
may act injuriously, and you should give it up, at least for some time, if 
it produces any bad effects. If it brings on heaviness, sickness of stomach, 
flushing of the face, excitement of pulse, and increased feverishness, give 
it up, and return for some time to the gruel and panado. You can try it 
again in a day or two ; for although your patient does not bear it to-day, 
he may to-morrow or the day after; and it is a most fortunate circumstance 
when it agrees with him, for, as I have already observed, it is the best 
kind of nutriment you can give in the middle and latter stages of fever. 



72 ON CLINICAL INSTRUCTION. 

Recollecting the tendency to diarrhoea and intestinal irritation in fever, 
you will be extremely cautious in allowing your patient the use of fruit. 
Indulging patients in the use of grapes and oranges is a very popular, but, 
in my mind, very hazardous and improper custom. I have on many occa- 
sions seen persons injured by fruit of this description. Stewed and roasted 
apples are still more dangerous; they are apt to produce tormina, flatu- 
lence, diarrhoea, and intestinal inflammation. All acid or raw fruit have a 
tendency to produce irritation of the stomach and bowels, and should be 
avoided altogether, or very sparingly used. 

One general observation as to the administration of food and nutriment 
in fever. All kinds of food and nutriment should be given by day, and 
the patient should, if possible, be restricted to the use of fluids by night. 
The natural habit is to take food by day and not by night, and in sick- 
ness as well as in health, we should observe the diurnal revolution of 
the economy. With respect to drinks, the mildest, of course, should 
be preferred: on this point most persons are generally agreed, and it will 
be unnecessar) for me to detain you with any particular observations. 
There is one error, however, which is very frequently committed in the 
use of drinks in fever; patients are generally allowed to drink too much. 
It maybe urged that they have a strong desire for /fluids; but they 
should not be gratified in every thing they wish for. They labour under 
a constant state of nervous irritation and restlessness, and will beg of you 
to do twenty different things to relieve their immediate feelings; but it 
would be just as improper to give them large quantities of drink every 
time they desire or call for it, as to indulge them in any momentary whim 
which may be the offspring of their disordered and changeable fancy. The 
continued swilling of even the most innocent fluids will bring on heavi- 
ness of stomach, nausea, pain, and flatulence, and predisposes to conges- 
tion and intestinal irritation. From the mere ingestion of a large quantity 
of the simplest fluid, you will frequently see well-marked symptoms of 
gastric irritation arise during the course of fever. This is not a picture 
drawn from imagination ; I have witnessed it on many occasions during 
the course of my practice. It is extremely painful, indeed, to be obliged 
to refuse drink to a patient labouring under intense thirst; but you should 
never allow them to take a large quantity of fluid at a time : you should 
impress upon them the danger attendant on such a practice, and tell them 
that a spoonful or two, swallowed slowly, allays thirst more effectually than 
drinking a pint at a time. The sensation of thirst, as you all know, is 
almost entirely confined to the fauces and upper part of the pharynx, and 
it is as much relieved by a small quantity swallowed slowly and gradually, 
as by a large quantity gulped down at once. 

Besides the simple fluids, there are other drinks required in fever. 
Beer, ale, porter, wine, tea, and coffee, are also frequently used in the 
treatment of fever, and are of the utmost value when employed on appro- 
priate occasions ; they are adjuvants of the highest importance in the 
dietetic management of fever, and it will require some time to explain the 
rules by which you should be guided in their administration. I shall 
therefore speak of them according to the indications with which they are 
given ; and, first, of tea and coffee. You are aware that we give seda- 
tives and narcotics to tranquillise, to produce a species of exhaustion of 
the mental faculties, and to bring on sleep ; and I do not see any reason 
why we should not also administer expergefacients, or remedies calculated 
to maintain intellectual activity, and keep the patient awake. Among 



FEVER. 73 

the remedies most frequently employed for the latter purpose, are tea and 
coffee. You have lately seen an infusion of green tea useful in a case of 
narcotism which occurred in the fever ward. A man in the latter stage 
of fever, and labouring under great nervous excitement and total loss of 
sleep, was ordered an opiate enema, after we had tried various other 
means without success. During the course of the evening he got twelve 
drops of black drop, with two ounces of mucilage of starch, in the form of 
enema, and soon after fell into a sound sleep. When we came next 
morning and inquired after him, every thing was reported to have gone 
on well ; the opiate enema had answered the purpose completely, and 
the man was still sleeping deeply. We found, however, on a more 
accurate examination, that he was in a kind of lethargic state, and could 
scarcely be roused. When addressed in a loud tone of voice, he raised 
himself heavily and slowly, half opened his eyes, gave a brief answer to 
our questions, and then, leaning back on his pillow, dropped asleep. 
Observe here the danger connected with this state. He was in an ad- 
vanced stage of fever, had been restless and sleepless, and had suddenly 
passed to an opposite state. The rapidity with which coma had super- 
vened on sleeplessness, and the danger of fatal congestion of the brain 
coming on, gave me considerable alarm. There was no use, however, 
in thinking of what had been done ; the man's state called for prompt 
and decided measures, and we proceeded at once to attack the symptoms 
of our own creation. One of the gentlemen went down and got some 
green tea, of which he made a strong infusion, and administered a strong 
dose of it to the patient. This had the desired effect ; the symptoms of 
coma gradually disappeared, and when I came to see him in the after- 
noon, he was quite out of danger. Green tea was first introduced here as 
an expergefacient in the treatment of coma by Dr. Edward Percival, son 
of Dr. Percival of Manchester ; and some years ago he read a paper at a 
meeting of the College of Physicians, in which he brought forward seve- 
ral cases of coma and stupor, in which green tea had produced the most 
favourable effects. On the continent they generally use strong coffee for 
the same purpose. Whether these beverages produce this effect by their 
influence on the circulation, or on the nervous system, I am not prepared 
to say ; but there cannot be a doubt of their efficacy and value in many- 
cases of this description ; and I am frequently in the habit of using both 
with this intention. 

W T hile on the subject of expergefacients, I shall beg leave to read for 
you a very curious case from the 13th number of the Boston Medical and 
Surgical Journal, in which an expergefacient of a less agreeable character 
was employed to rouse a patient from the lethargic stupor brought on by 
a large dose of laudanum. There are some transatlantic peculiarities of 
expression in the detail of this case, but I have no doubt of its being cor- 
rect. It is entitled u a case of successful treatment by flagellation, where 
a large dose of laudanum had been taken." And the author, Dr. Joseph 
Barret, of Middleton, Connecticut, proceeds as follows: 

u Tincture of opium is not unfrequently resorted to for destructive pur- 
poses. It is also, unfortunately, and too frequently, taken by mistake, and 
proves fatal before efficient means can be adopted to counteract its delete- 
rious effects on the system. I am induced, therefore, to offer a short state- 
ment of a case of poisoning with laudanum that fell under my care seve- 
ral years since, for the following reasons : first, the success that attended 



74 ON CLINICAL INSTRUCTION.' 

the mode pursued, and, secondly, from not having met with any such 
means recorded, to my knowledge,* either in works on medicine, or in 
treatises on poisons." 

Observe, it is not I that am speaking here, but Dr. Barrett, of Middle- 
ton, Connecticut. 

" In the year 1822, February 23d, I was called on to see Mr. Wright 
Harris (this was in the state of New York), who had intentionally taken 
a large dose of laudanum for the purpose of destroying himself. He had 
committed this act during his absence from home, under circumstances 
which it is not important to relate. Much time, about three hours, was 
therefore lost, before any effectual measures could be adopted for his relief. 
His case, as I found him, appeared to be altogether hopeless. Before my 
arrival, emetics and various drinks had been tried, besides frictions, and 
constant, though ineffectual attempts, had been made to irritate the oeso- 
phagus by feathers. All these means had failed, and the patient was in 
such a profound sopor, that apparently nothing but warmth remained to 
indicate that life had not already become extinct. The quantity of lauda- 
num taken was ascertained to be one ounce and a half. The case appear- 
ing so desperate, justified me in the course of treatment which I was, under 
existing circumstances, then obliged to adopt. 

" Internal remedies having entirely failed, there was no chance left but 
for high external excitements. I therefore determined to use vigorous 
measures. I commenced with flagellations, using long pliant, fresh twigs, 
to the palms of the hands and soles of the feet. These were briskly applied, 
and in a short time gave indications of uneasiness and pain. This treatment 
was unremittingly pursued till the man spoke, and complained of being 
pained by the whipping, when this severe appliance was relaxed ; but on so 
doing, he instantly sunk into a profound stupor, from which he was again 
only roused by the severity of the whipping. It required the aid of a 
number of men to take turns in the flagellation, as well as to support and 
walk him about ; for a cessation of the use of the rods was followed by 
instantaneous stupor. After about six or eight hours under this course, the 
stupor was lessened, and the severity of the flagellation mitigatedj; but as 
the case required constant high excitement, it was still repeated at inter- 
vals, till eventually the exercise of walking was sufficient to keep him 
awake. This was in about twelve hours from the commencing with the 
flagellation. He afterwards experienced but little inconvenience from his 
hands and feet, and was perfectly restored in a few days to his usual 
health. I would here state that the first proposal made by me to adopt 
flagellation, as the only hope, was objected to by the persons present, from 
its carrying with it the semblance of unkindness towards what was re- 
garded by them as a corpse ; and it was not till the application of the 
rods by myself, in the first instance, that I obtained the aid of those pre- 
sent ; but as soon as the patient began to move, and at last spoke, they 
took hold with alacrity, and by dividing themselves into relief parties, they 
very cheerfully, and rather amusingly, kept up the castigation so long as 
the state of the patient required it at their hands. He by no means seemed 
to relish this harsh proceeding, and in return gave his attendants several 
severe blows. If while lifting his arm to give a blow, the flagellation 
was then entirely suspended, the arm would instantly sink powerless; to 

* This practice, though not generally adopted, has been recommended by several authors in 
Europe. 



FEVER. 75 

such a degree had the effects of the narcotic drug prevailed over the ner- 
vous system, that nothing but the torture of the rods could rouse him. 
On his recovery, it was said that the man's wife was highly satisfied with 
this remedial course, which was believed to have a good effect upon his 
subsequent conduct." 



LECTURE VI. 

Treatment of Typhus Fever — Tympanitis often the consequence of inattention to diet, or to 
overdosing with purgatives — The uses of air in the Intestines — Treatment of Tympanitis 
unaccompanied hy Intestinal Inflammation — Utility of Spirit of Turpentine in such cases — 
Tympanitis with Inflammation and Congestion of Intestines — Acetate of Lead best remedy 
— Turpentine in Iritis. 

Before I proceed to speak of the diet and remedies to be employed in 
the treatment of typhus, allow me to make a few observations. There is 
a patient at present in the fever ward, whose case shows the necessity of 
strict attention and incessant watchfulness on the part of those who have 
the management of bad cases of fever. A man who has been labouring: 
under delirium, with symptoms of cerebral excitement and congestion, 
was ordered the tartar-emetic solution, with the view of reducing the 
increased vascular action ; but on inquiry this morning, we find that he 
has taken no medicine, and that his symptoms have been allowed to go on 
unchecked for twenty-four hours. He refused to take his medicine, and 
the nurse very improperly neglected to report the circumstances of the 
case, in order that proper steps might be taken to remedy so dangerous 
an omission. Thus a whole day has been lost at a most critical and im- 
portant period of fever. There can be no excuse for such negligence as 
this, for it could be easily remedied. Patients in this state have always 
more or less thirst, and a spoonful of the tartar-emetic solution could be 
mixed with whey or cold water, and administered in this way without 
his knowledge, or if he refused to drink any fluid, it might be given in 
the form of enema. There is no excuse, therefore, for such negligence ; 
and when you recollect the state that such patients are in — their nervous 
excitement, incessant raving, agitation, struggling, and sleeplessness — 
you will be able to appreciate the dangerous, and even fatal, consequences 
that may arise from culpable neglect of this kind. 

At our last meeting I spoke of the use of food and drink, and laid 
before you my views of the most appropriate articles of diet in the various 
stages of fever. I told you that I attributed much importance to the use 
of a proper regimen, and that I looked upon the observance of this prin- 
ciple as a main cause of success in the treatment of typhus. I think it is 
chiefly owing to our care in this respect, that so few of our patients have 
tympanitis. Now and then we have cases of fever with tympanitis and 
diarrhoea, but in the majority of instances, these are persons who have 
been under treatment before admission, and who have been too much 
purged. The use of drastic purgatives in the early and middle stages of 
typhus, is one of the most fertile sources of subsequent evil, and there are 
few evils of greater magnitude than tympanitis with diarrhoea, and gastro- 
enteric inflammation, particularly in the latter stage of fever. Now, if 



76 ON CLINICAL INSTRUCTION. 

you inquire into the history of the cases in which these symptoms are most 
distinctly marked, you will find that in at least two-thirds, powerful 
cathartics have been employed, not once, but repeatedly, in the com- 
mencement of the disease. Almost all cases, in which calomel and colo- 
cynth, or aloes, followed by black draught, have been liberally used in 
the commencement, become tympanitic, frequently at a very early period.* 
The same mischief, but in a less degree, is apt to occur where a system 
of strict abstinence has been enforced, and continued undeviatingly for a 
considerable length of time. Want of food, even in the healthy state of 
the system, is apt to produce flatulence, weakness, and distension of the 
stomach, and in many instances gives rise to very serious forms. of gastro- 
intestinal irritation. The dilte absolue is very apt to produce the same 
effect in fever. Even the abuse of drinks of the simplest and most inno- 
cent description, is apt to produce flatulence, distension, and a tendency 
to tympanitis. Hence the value of the rule which I laid down in a for- 
mer lecture, viz., to allow the patient only small portions at a time, and 
to order him to swallow them slowly. The abuse of the ordinary drinks, 
as common water, whey, barley-water, soda and seltzer waters, and effer- 
vescing draughts, is a frequent source of tympanitic swelling in fever. 

Having commenced the subject of tympanitis in fever, I cannot do 
better than introduce in this place a paper I published in the 8th volume 
of the Dublin Medical Journal, where the subject is treated of at consi- 
derable length. The paper is headed, " Tympanitis occurring in Fever, 
and the different modes of treating it." 

* The views of my colleague quite agree with mine — 

" A common practice has prevailed in these countries, and, indeed, still exists to a very great 
extent, of making the patient take purgative medicine every day; and this, I regret to say, is 
too often done even in cases where the surface of the small intestine presents extensive patches 
of ulceration. Now I will ask you. can any thing be so barbarous as this, or can it be exceeded 
in folly or mischief "by the grossest acts of quackery 1 Here we have an organ in a state of 
high irritation, and exhibiting a remarkable excitement of its circulation ; and yet we proceed 
to app'y stimulants to that organ, and to increase the existing irritation. Would it not be 
absurd in a case of inflammation of the knee or elbow-joint to direct a patient to use constant 
exercise and motion ] Would it not be a very strange practice to apply irritants to a raw and 
excoriated surface 1 Yet something equally absurd, and equally mischievous, is done by those 
who employ violent purgatives in a case of inflammation of the digestive tube in fever. This 
has been a great blot in the history of British practice. Calomel and black bottle, and even 
jalap and aloes, and scammony, have been prescribed for patients labouring under severe and 
extensive dothinenteritis. Morbid stools are discharged, and the more morbid they are, the 
more calomel and purgatives does the physician give to change their character, and bring them 
back to the standard of health. I want words to express the horrible consequences. Too 
often have I seen fever patients brought into the hospital with diarrhoea, hypercatharsis, and 
inflammation of the mucous membrane, from the use of purgatives administered before their 
admission. Practitioners will not open their eyes. They give purgatives day after day, a very 
easy practice, and one for which there are plenty of precedents; but it is fraught with the most 
violent consequences. I will freely admit that the disciples of the school of Broussais have 
gone too far in decrying the use of laxatives altogether. But if they have lost hundreds by this 
error, British practitioners have killed thousands by an opposite plan of treatment. In cases 
of fever where there is no decided symptom of gastro-enteric disease, there can be no objection 
to the use of laxatives if required, but they should always be of the mildest description. You 
will gain nothing by violent purging in fever, mild laxatives alone can be employed ; and where 
there is any sign of intestinal irritation present even these should be used with caution. There 
is one mode of opening the bowels, which you may always have recourse to with advantage in 
fever, viz., the use of enemata. There is not the slightest doubt that occasionally accumula- 
tions of fecal matter will take place, and tend to keep up irritation, but they should always be 
removed with the least risk of producing bad consequences. To purge in fever when intestinal 
irritation is present, is a practice opposed alike to theory and experience, and I have already 
stated that its results are most horrible," — Doctor Stokes's Lectures, American Edition, 
p. 500. 



FEVER. 77 

The mucous membrane of the alimentary canal secretes air in great 
abundance during health. The immediate uses of this secretion have not 
been enough studied, nor have I now sufficient space to dwell on this sub- 
ject ; it may be remarked, however, that the presence of air in the bowels 
must be of great importance, both physically and chemically assisting 
digestion, which essentially consists in the gradual softening and final 
solution of the solid food, and the absorption of the dissolved portions. 
Physically the air must facilitate the motions of the alimentary bolus, 
keeping the bowels in a suitable state of distension, and being ready imme- 
diately to occupy the place of the solid or fluid contents as they are moved 
about or absorbed; chemically, it is known that certain gases, such as 
carbonic acid, a gas always very abundant in the intestine, possess a 
remarkable power of rendering various solids more readily soluble in water, 
particularly when these gases are subjected to the effects of pressure in 
close vessels along with the solvent fluid, a state of things which exists 
also in the intestines ; another chemically powerful gas secreted by the 
mucous membrane of the bowels is sulphuretted hydrogen. In the upper 
portion of the canal common air is most abundant, in the lower the two 
other gases become predominant, a distribution not fortuitous, but no doubt 
destined to fulfil important purposes. It appears, indeed, that these por- 
tions of the alimentary canal, which secrete fluid acids (the muriatic and 
acetic) in abundance, do not secrete acid gases, while the remaining 
portions secrete these gases in greater abundance, so that the one may be 
considered as supplemental to the other. I am not aware that physiolo- 
gists have as yet considered this subject in the point of view here brought 
forward,* although it evidently illustrates many things connected with 
practice. Thus I have frequently remarked, and I would call attention to 
the fact, that in persons labouring under dyspepsia, and in whom the 
derangement appears to be limited to the stomach, the supplementary 
digestion in the small intestines appears to be carried on with great 
activity. Such persons suffer much immediately alter having taken food ; 
they experience an oppressive sense of weight about the stomach, with 
flatulence and distension ; in fact, they feel exceedingly uncomfortable 
until the food passes into the duodenum, where the digestive power is in 
full vigour and activity. As soon as this occurs, the sense of weight and 
distension rapidly disappears, and they are no longer troubled with flatu- 
lence. I have further noticed, they do not lose flesh or strength, and an 
inspection of their alvine discharges has shown that every particle of nutri- 
tious principle has been absorbed and found its way into the system. 
This I have frequently observed. Persons will apply for advice who have 
been for a long time labouring under symptoms of derangement of the 
stomach, yet they are by no means emaciated, and are quite capable of 
discharging the duties of situations which require great mental and bodily- 
activity. This shows that if the process of digestion does not go on well 
in the stomach, it must somewhere else. If, in such a case, the stomach is 
weak and unable to perform its functions, the remaining part of the 
digestive tube is strong, and pours out the fluids necessary for completing 
the process with great energy. Again, we meet with many persons who 
never complain of acidity, pain, flatulence, or sense of distension and 
weight in the stomach, and yet they are frequently annoyed with un- 

* This view of the uses of air in the alimentary canal, published in 1836, has been com- 
pletely verified by the subsequent researches of Liebig. 



78 ON CLINICAL INSTRUCTION. 

pleasant abdominal sensations ; they have costive or irregular bowels, 
diarrhoea, tormina, tympanitis, fetid unhealthy evacuations, and scanty 
high-coloured urine. They feel uncomfortable, not immediately after a 
meal, but in three or four hours ; they lose flesh and strength, and have a 
pale sallow unhealthy look. Here the dyspepsia is intestinal : the stomach 
works well and performs its functions with vigour, but when the alimen- 
tary mass enters the small intestines, it produces a great deal of discomfort, 
because the supplementary digestion is deranged, and its performance 
attended with much labour and difficulty. In some cases both these forms 
of dyspepsia are combined, and these are of course the worst ; but they 
exist quite distinct from each other, and a patient, with his stomach in a 
perfectly normal and healthy state, may labour under dyspepsia from 
derangement of the digestive functions of the small intestines, or with the 
latter in a healthy state, he may have indigestion from simple gastric 
derangement. We have reason to conclude, that when organic or func- 
tional disease so impairs the energies of the stomach that it assists but 
little in the performance of digestion, the intestinal digestion becomes 
more intense ; it is only thus that we can account for the absence of 
emaciation in certain cases, such as that of Napoleon Buonaparte, where 
nevertheless the stomach was so extensively disorganised as totally to 
prevent its taking any part in the process of digestion. 

The preceding remarks, though not directly connected with, are never- 
theless illustrative of the subject under consideration — it being evident 
that the secretion of air natural to the mucous membrane of the intestines 
during health, may readily be augmented in disease, so as to give rise to 
intestinal tympanitis. This happens in all cases where inflammation or 
congestion attacks this tissue, an occurrence particularly frequent in fever. 
When tympanitis takes place in the commencement of fever, it invariably 
proceeds from inflammation, and is usually preceded by tenderness and 
other unequivocal symptoms of inflammatory action within the abdominal 
cavity. The remedy for this complication consists in local blood-letting 
freely applied, together with small doses of Dover's powders, with con- 
siderable doses of pulvis hydrargyri cum creta ; all active aperients should 
be avoided, but emollient lavements are often useful. When tympanitis 
occurs, during the middle or latter stages of protracted fever, it sometimes 
is inflammatory, but more frequently depends on a state of venous con- 
gestion, occupying a considerable extent of the mucous membrane of the 
small intestines, which subsequently becomes gorged with blood, and livid, 
and secretes, among other morbid matters, a large quantity of gases. This 
tympanitis is often preceded by bowel complaint, unaccompanied by 
abdominal tenderness or pain, in the first instance ; a state of things which 
may last for one or several days before inflation of the intestines com- 
mences. When this occurs, then, if it proceeds rapidly, the belly becomes 
painful and swollen on account of the sudden distension ; and a superficial 
observer is thus apt to attribute the tympanitis to active inflammation. 
Now, as this state of things takes place at a period of great debility, when 
the powers of life are already much exhausted, and when even the appli- 
cation of a few leeches may be followed by alarming weakness, it is 
evident that this tympanitis must be treated in a manner different from 
that spoken of. In general, it will be right to commence with the exhi- 
bition of ten or fifteen grains of magnesia, with the same quantity of 
rhubarb, given in some carminative water, such as aqua mentha? viridis, 



FEVER. 79 

or aqua funiculi; when this has operated the belly should be well stuped 
and rubbed with a stimulating terebinthinate liniment. It often happens, 
that after the operation of the rhubarb, the diarrhoea, and with it the 
tympanitis, begins sensibly to diminish, and then a little care will 
soon remove these symptoms altogether. Sometimes, however, no such 
improvement follows ; and the belly continues to swell while the bowel 
complaint is unchecked. This is a dangerous crisis, and requires the 
utmost judgment in its treatment. It is of great consequence to remark, 
that when the bowel complaint has preceded intestinal tympanitis in fever, 
and when, notwithstanding the continuance of the bowel complaint, the 
tympanitis has gone on increasing, spirit of turpentine will seldom be of 
the least use, whether exhibited by the mouth or in an enema. We must, 
therefore, under these circumstances, look for some remedy different from 
those usually recommended, and such remedy we possess in the acetate of 
lead. Pathologists are agreed that venous congestion and active inflam- 
mation of the intestinal canal may often be associated together ; and, in 
fact, although these two states are different, and require different remedies, 
yet they so often approach each other as to require medicines taken from 
the class of antiphlogistics ; the one requires, however, a very different 
antiphlogistic from the other, just as chronic dysentery must be combated 
by remedies different from those suited to acute bowel complaint. Spirit 
of turpentine is admirably suited to the cure of congestive tympanitis in 
fever, where no bowel complaint, or a very slight one, has preceded or 
accompanied it. < But is spirit of turpentine an antiphlogistic remedy ? 
I answer, does it not cure certain cases of iritis, of sciatica, and of 
epilepsy? When, however, a bowel complaint forms the chief feature 
in a patient's state, and is associated with tympanitis, then the acetate of 
lead must be our sheet anchor. I was first led to use this medicine in 
considerable doses, in the latter stages of protracted fever, on the recom- 
mendation of Dr. Bardsley, for the purpose of preventing that state of 
the bowels which so insidiously leads to ulceration of Peyer's glands. 
Dr. Bardsley certainly deserves much credit for the introduction of this 
remedy, with which I became familiar in consequence o^ using it largely 
in Asiatic cholera, a disease in which the serous discharges are almost 
invariably preceded, and, when the patient recovers, invariably followed 
by a copious secretion of air into the boicels. This it was that led me to 
observe the anti-tympanitic properties of the sugar of lead ; for I found it 
to be a remedy, not merely for the secretion of serous fluid into the intes- 
ti?ies, but for the secretion of air in that disease. Afterwards, analogy led 
me to apply it to the cure of tympanitis, combined with diarrhoea, in the 
middle or latter stages of typhus fever, and I have had much reason to 
congratulate myself upon this new application of the remedy, for it has 
been very successful in my hands. It may be well to observe, that sugar 
of lead, besides its astringent, seems to possess antiphlogistic properties; 
otherwise we could scarcely account for its good effects in active hemor- 
rhage, and in violent action of the heart, for which latter it is much cele- 
brated in France, when given in large doses. 

In the above sketch of the treatment of tympanitis, my chief object 
being to point out the circumstances in which acetate of lead may be used, 
I have omitted mentioning many other remedies and methods of treatment 
as sufficiently known by practitioners in general ; among these, probably 
none is more effectual than leeching the anus in inflammatory cases, and 



80 ON CLINICAL INSTRUCTION. 

in all mercurial dressing applied over a very large vesicated surface on 
the abdomen. 

As I have mentioned spirit of turpentine as a cure for iritis, as first re- 
commended by Mr. Hugh Carmichael, it may be well to observe, that it 
is extremely useful when, by judicious mercurialization of the patient, the 
destructive progress of the disease is arrested, but, as happens not unfre- 
quently again, recommences, notwithstanding that the patient's mouth is 
still sore, nay, though he may be salivated. Then it is that spirit of tur- 
pentine often acts like a charm, and prevents the necessity of recurring to 
mercury a second time ; it has also been found extremely useful in in- 
stances, where, notwithstanding that the patient has been judiciously sali- 
vated, yet no improvement has taken place in the diseased eye : in such 
cases the most satisfactory results have been observed to follow its exhi- 
bition.* 

Having dwelt at considerable length upon tympanitis, I shall now make 
a few observations upon hiccup. 

When hiccup occurs in typhus fever, it is generally owing to a con- 
gested state of the mucous membrane, accompanied by flatulent distension 
of the stomach and bowels. A remarkable case of this sort occurred to 
Doctor Ireland and myself, in w^hich a corpulent man, labouring under 
maculated typhus, hiccupped during several days, more than eighteen 
hours out of the twenty -four, as was ascertained by notes kept by his sis- 
ter, who carefully watched him. 

In such cases, the treatment adapted to tympanitis in typhus fever is 
most appropriate for the removal of that affection, and therefore much 
variety of treatment is required. Thus, when hiccup occurs early in the 
disease, along with much thirst, parched tongue, and tender epigastrium, 
the treatment ought to consist of leeches to that part, iced water in small 
quantities, dille absolue, and bland aperient injections. But when it comes 
on late in the disease, we must have recourse to stimulating liniments 
applied to the spine ; blisters to the epigastrium ; and if the bow T els are 
at the same time confined and distended, spirit of turpentine internally, 
or by lavement, while the strength is supported by wine and proper nutri- 
ment. Here the spirit of turpentine is best given in doses of two or three 
drachms, combined with castor oil : but on the other hand, when diar- 
rhoea is present, together with tympanitis, we must have recourse to ace- 
tate of lead, as recommended in tympanitis, to various stimulants in small 
and repeated doses, such as turpentine, ether, &c, combined with opium. 
In fever, hiccup occasionally occurs without any obvious derangement of 
the alimentary canal being present, and without our being able to detect 
any cause of this symptom. Our treatment under such circumstances 
must be empirical, and relief will be frequently obtained by the exhibition 
of some substance which has an obvious action on the nervous system ; 
but, as I have said, our treatment must be empirical* — in one patient we 

* There is no mention made of the use of turpentine in iritis, in the latest work on Materia 
Medica, namely, that by Dr. Christison. Such an omission admits of no excuse. 

■J- My colleague, Dr. Storks, thinks that the period of fever, when hiccup occurs, will guide 
us to the line of treatment we should adopt. This does not accord with my experience; for, 
except in the particular cases I have described, I know of no certain rule by which to regulate 
our treatment. 

He says — " In the early period of fever, I have found it (i. e., hiccup) co-exist with inflam- 
mation of the cardiac orifice of the stomach ; in the advanced stage, as far as my experience of 
it goes, it seems to be more connected with general lesion of the nervous system. With these 



FEVER. 81 

may find success attend the exhibition of an alkali, in another, of an acid. 
The same observation applies to swallowing of ice, or water as hot as it 
can be drunk, to the various narcotics and stimulants, to musk and cam- 
phor, &c, &c. 



LECTURE VII. 

Thirst in fever frequently dependent on the state of some internal organ — Blisters, employed 
as stimulants and evacuanis, excite the vital action of the capillaries — An important remedy 
where cerebral affection is apprehended — Signs of approaching cerebral symptoms — Tartar 
emetic, solution and ointment — The latter used with success in some desperate cases. 

In this hospital we seldom prescribe effervescing draughts, and never 
give them in the ad libitum quantity which some persons recommend. 
Thirst can be sufficiently assuaged by the use of whey, or common water, 
acidulated with currant jelly or raspberry vinegar, given in small portions, 
and at certain intervals. Sometimes you will succeed effectually in con- 
trolling feverish thirst by the use of a very light infusion of cascarilla, 
acidulated with a small quantity of muriatic acid. I have seen this em- 
ployed with success by Mr. Kirby, and I have often prescribed it myself 
with the best effects. Very often a small quantity of some light bitter, 
slightly acidulated, will appease the morbid thirst of fever more effectually, 
and for a much longer period, than large draughts of water, or any of the 
fluids usually employed for the same purpose. You should always bear 
in mind, that thirst in fever does not exclusively depend on a dry or 
parched state of the mouth or fauces, but lies much deeper in the system, 
and has its origin in some peculiar derangement of the nerves > most pro- 
bably of those belonging to the ganglionic system. In going through a 
fever ward, you meet with numerous illustrations of the truth of this posi- 
tion ; one man with a moist tongue and fauces, labours under insatiable 
thirst, while you will observe another with parched tongue and throat, 
and yet without any desire whatever for fluids, or any choice as to their 
temperature. We had two examples of this in the fever ward during the 
past week. One patient with a moist tongue was incessantly calling for 
drink, while another man, who had his tongue almost perfectly dry, e~ 
hibited a very remarkable indifference to fluids. 

There is a curious circumstance connected with the sensation of thi 
in inflammatory diseases, which deserves attention. I lately attended . 
fatal case of metritis after delivery, in consultation with Mr. Hayden and 
Dr. Ireland. These gentlemen pointed out to me the singular fact, that 
the patient's thirst was instantly increased to an intolerable degree, by 
pressure applied to the womb. I merely notice the fact here as being ex- 
tremely curious, leaving the explanation of it to those who are more con- 
versant with such investigations.* 

views, we may divide the treatment of hiccup into two parts : first, that which occurs in the 
early stage of fever, and, in the next place, that which comes on towards the close of the dis- 
ease. In the former, we have found leeching, cold drinks, and abstinence, the best remedies; 
in the latter, antispasmodics and stimulant remedies appear to be more applicable. By reason- 
ing, then, from experience, we find that hiccup, in the beginning of fever, demands local anti- 
phlogistics; but in the latter periods, when there is profound adynamia, it may be treated with 
opiates, antispasmodics, and even stimulants." — Stokes's Practice of*\ledieine,*1m. ed. p. 499.. 
* The opinions advanced in the text are strongly confirmed by the views of Dr. Carpenter: 
" The conditions of the sense of thirst appear to be very analogous to those of hunger. This 

7 



82 CLINICAL MEDICINE. 

Having said so much of food and drink in fever, I come now to speak 
of external and internal remedies, and first of blisters. Blisters are em- 
ployed in a variety of diseases, but are followed by very different physio- 
logical effects, and capable of serving very different purposes, according 
to their mode of application. In fever they are generally employed either 
as stimulants, or as evacuants and derivatives. As stimulants, they may 
be used with the intention of rousing the depressed energies of the system 
in general, by their action on the nervous and circulating systems, or of 
stimulating the torpid functions of some particular part or organ. With 
this object in view, they are applied as flying blisters — that is to say, for 
a space of time not exceeding two or three hours, and solely with the in- 
tention of producing a stimulant effect. You have seen some cases of 
fever in our wards, in which the powers of life were greatly depressed, 
the extremities cool, the action of the heart feeble, the pulse weak, respi- 
ration short and imperfectly performed, and a tendency to faintness and 
sinking ; and you have observed that in such cases we derived great 
benefit from the application of flying blisters over the regions of the heart, 
the epigastrium, chest, and inside of the legs and thighs. We applied 
our blisters in these situations, left them on for two or three hours, and 
then removed them ; and you have seen them, when employed in this 
way, succeed in rousing the vital energies, the depressed -action of the 
heart and capillary system, and the flagging state of the respiratory action, 
as shown by the increased strength of the pulse, the more general diffusion 
of heat, and the renewed play of the various functions. 

In such cases, where the stimulant effect alone is required, it would be 
wrong to leave the blisters on longer than two or three hours ; it will be 
quite sufficient if they prove merely rubefacient, or, at most, vesicate so 
slightly as to give to the blistered surface the appearance of a miliary 
eruption. Here you have all the stimulant effects of blistering, but not 
followed by their debilitating consequences. You are aware that blisters 
applied in the ordinary way have a twofold effect ; they first rouse, and 
then depress ; acting primarily as stimulants, and secondarily as evacuants. 
They first act as stimulants, producing pain, heat, and redness of the part ; 
after a few hours these symptoms diminish, and are followed by an effu- 
sion of serum — in fact, a quantity of white blood is abstracted from the 
cutaneous capillaries, and in this way an evacuation is produced, calcu- 
lated to diminish any accidental congestion in neighbouring parts. The 
capillaries, by means of their increased action, draw a quantity of white 
blood to the part ; and in saying this, I think I am only using a perfectly 
physiological expression for the quantity of circulating fluid in any part of 

sense is not referred, however, to the stomach but to the fauces. It is generally considered 
that it immediately results from an impression made on the nerves of the stomach, since, if 
liquids are introduced into the stomach, through an oesophagus tube, they are just as effectual 
in allaying thirst, as if they are swallowed in the ordinary manner. It may, however, be 
doubted whether the sense of thirst is not even more immediately connected with the state of 
the general system than that of hunger; for the immediate relief afforded by the introduction 
of fluid into the stomach is fully accounted for, by the instantaneous absorption of the fluid 
into the veins, which is known to take place, when there is a demand for it, not only from Dr. 
Beaumont's observations, but from many experiments made with reference to this particular 
question. This demand is increased with almost equal rapidity by any excess in the amount 
of the fluid excretions ; and it may be satisfied without the introduction of water into the sto- 
mach. Thirst may also be produced, however, by the impression made by peculiar kinds of 
food or drink upon the walls of the alimentary canal." — Dr. Carpenter's Principles of Hu- 
man Physiology, page 35C. 



FEVER. 83 

the body must depend on the vital action of the capillary vessels of that 
part. It is to the peculiar state of the capillary vessels that the quantity 
of blood in any part is to be referred, and not to the force or frequency 
of the heart's action. It is by means of changes produced in them that 
the phenomena of active congestion, and inflammation are produced ; the 
capillaries of the affected part enlarge, increase in number and multiply, 
and those which were invisible become visible. These phenomena have 
been falsely attributed by Hastings and others to debility and impaired 
action of the capillaries. 

Enlargement or distension of the capillary vessels, whether the result 
of active local congestion or inflammation, is quite a different process, and 
bears a very close analogy to the enlargement of the anastomosing arteries 
of a limb in which the principal vessel has been tied. The afflux of blood, 
and the vascular distension, are not the consequences of debility or of re- 
laxation, but of an actual increase of vital action. In the enlargement of 
the anastomosing arteries which takes place in cases of collateral circula- 
tion, the increase of size is not confined to the arteries connected with the 
main trunk ; it commences simultaneously in the more distant set of 
branches, beginning in the smaller ones, and then gradually extending to 
the larger. This is a proof that the enlargement of the vessels depends 
solely on a vital action inherent in themselves, and is not the result of a 
mere passive distension, or of an increased determination of blood to the 
part, produced by the action of the heart. 

Dr. Houston, in a very important paper on the circulation in a mon- 
strous foetus, without head or brain, published in the x. vol. of the Dub- 
lin Medical Journal, has proved to a demonstration, that, in the case re- 
ferred to, the circulation in the placenta could not be carried on, unless 
by the vital attractive power of the capillaries. It is owing to this power 
that vascular tumours bleed so profusely when wounded or scratched : 
and yet, if you cut through the artery which supplies them, there will not 
be any considerable hemorrhage. When you divide the artery, the capil- 
laries cease to draw blood to the part, and the hemorrhage is slight ; but 
if you wound the tumour itself, the blood is attracted to the part as fast 
as it drains off, and a profuse hemorrhage is the result. 

You should also bear in mind, that there are many animals which are 
without a heart, and yet in which the functions of the circulation are ade- 
quately performed. We have numerous instances of human monsters 
born without any trace of a heart, and yet well nourished and developed. 
In cases of this description how is the circulation carried on, or by what 
power is the blood impelled through the vessels? I do not see what 
cause we can refer it to, except the vital agency and attractive power of 
the capillary system. I mention these facts because, in the treatment of 
inflammatory and febrile affections, it is important that you should have 
correct physiological views, and that you should bear in mind, that each 
part and organ of the body may have its vital action deranged, or, in other 
words, may become congested and inflamed, independently of the action 
of the heart or of the general circulation.* 

* I shall here lay before the reader an extract from the paper of Dr. Houston, referred to in 
the text. The paper is entitled •• An Account of a Human Foetus without Brain, Heart, or 
Lungs ; with observations on the Nature and Cause of the Circulation in such monsters. By 
John Houston, .M.D." — Dublin ^Medical Journal, vol. x. 

" A healthy young woman gave birth to twins between the seventh and eighth months of 
her first pregnancy. They were borne in quick succession, and the placenta came away imme- 



84 CLINICAL MEDICINE. 

Blisters, then, produce first increased action of a part, and then act as 
evacuants. They also stimulate the system generally ; but if left on until 

diately thereafter. One of the children was, to outward appearance, perfect in every particular, 
and of full growth for its age. The other, a female, the subject of this communication, was a 
monster, and of somewhat smaller size than its companion. Both were alive at the time of 
delivery, but died almost immediately after. The placentae were so intimately united as to 
appear to constitute but a single organ; but the marks of their union showed* that one was 
scarcely half the size of the other. There was a separate cord and separate set of membranes 
for each foetus. The points of attachment of the coids to the placentae were several inches 
asunder. The abdominal foetus had no cranium, and consequently no brain. The spinal 
column commenced at the sixth cervical vertebra. The two first vertebra? were imperfect, and 
without spinal canal ; all the remainder were perfect in every respect. A large watery tumour, 
having somewhat the appearance of a head, occupied the upper part, and extended down along 
the back. There were no upper extremities, not even clavicks ; there were twelve ribs, but 
no sternum ; there was no diaphragm, and consequently no subdivision of the cavity into chest 
and abdomen ; there were neither lungs nor heart, nor thymus gland ; and the liver was totally 
wanting. The kidneys were of inordinate size, nearly filling the abdomen, and pressing up- 
wards on each side, to the apex of the cavity formed by the ribs*; a large ureter rose from the 
inside of each. J\o vestiges of supra-renal capsules could be discovered." 

It is unnecessary to detail any further particulars of this monster, and I shall pass at once to 
the observations which Dr. Houston makes on the circulation. 

" Supposing however it were possible that the heart of the perfect foetus might assist, in a 
slight degree, to propel the blood into the body of the imperfect one, by what agency then shall 
that blood be driven out of that body again 1 It cannot be accredited that the remote heart of 
the second foetus would have power, after conducting the circulation in the individual to which 
it properly belongs, to drive the fractional surplus of its blood, with all the rest belonging to 
the placenta of the monster, not only into that monster, but out of it again. 

" It must, therefore, appear evident thai the vis a tergo imparled by the heart of the perfect 
twin, cannot be the sole moving cause of the circulation in its abdominal companion, no mat- 
ter in what light we view the application of the force in question. A healthy foeius of this 
kind stands perhaps in the same light, in reference to the influence of a heart'on the circula- 
tion, as one of the same description without a companion in utero, and in which, of course, 
the blood should take its rounds, totally unaided by any mechanical vis a tergo. But even in 
the perfect foeius, while it remains connected with the womb, the heart does not fulfil the same 
important offices as after the individual is brought into a condition of independent life, for there 
is in all cases a period, and that, too, long after the growth of the foetus has commenced, in 
which there is no heart at all, and in which nothing but vessels are discernible ; and there are 
other instances in which throughout the whole period of foetal existence, the organ never ac- 
quires perfection ; and, nevertheless, we do not find that, under either of these circumstances, 
the blood fails to flow through the body ; whatever parts are developed in such cases receive 
an abundant supply of that fluid. This question might be still further elucidated by a refer- 
ence^ the state of the circulation in many of the lower animals ; but enough — sufficient has 
been advanced to show that the heart is not an indispensable organ in foetal life, and that the 
circulation of the blood at this period is not solely due to its influence. It grows simultane- 
ously with the other organs, but does not appear so much to have reference to the existence 
of the foetus while in the womb, as that it may be in readiness for operation after birth, when 
exterior mechanical agencies demand more precision and force of progress in the circulating 
fluids. Such passive energy on the part of the heart is not without analogy in the body of the 
foetus; for there are many other organs, such as the lungs, intestinal canal, &c, which are pre- 
cisely in this predicament. But in thus quesfioning the power of the heart as being solely in- 
strumental in accomplishing the transmission of the fluids through the body of the foetus, I am 
not prepared with any new explanation likely to account for the phenomenon. The theory of 
" vital attraction and repulsion," though conveyed in terms which may be considered more as 
expressive of the facts than as explanatory of them, appears to me to approximate more nearly 
to the true one than any which has been yet broached. And 1 may here introduce the state- 
ment of a fact which appears to have passed unnoticed, but which places in a strong light the 
influence of vitality on the circulation through animal bodies. The leg of a man amputated 
by Surgeon Trant for mortification after fever, was submitted to me for examination. The 
foot was black, shrivelled, and dry, and a line of separation had passed deeply through the 
skin and cellular membrane, a little above the ankle; the foot had been cold and insensible for 
weeks. I threw some common injection into the tibial arteries, and, to my surprise, this coarse 
fluid passed into the foot, filling all the digital arteries, and even the smaller twigs among the 
muscles. The other foot, which mortified at the same time, but which was not removed for 
three weeks subsequently, and until the line of separation had extended into the joint in several 
places, had exposed all the tendons, and divided the posterior tibial artery completely through, 



FEVER. 85 

full vesication is produced, they act as evacuants and depletives, and lower 
the general tone of the economy. I have frequently observed this suc- 
cession of events in chronic cases, in which it was found necessary to 
blister repeatedly during the course of the disease. The patients gene- 
rally told me that they felt better and lighter on the day on which the 
blister was applied, but on the next day they usually felt weaker and 
more depressed ; and this state sometimes lasted more than a single day. 
You may therefore apply blisters as excitants and stimulants, or you may 
employ them as evacuants and depletives ; yet there are many persons 
who seem to forget this distinction. If in a case of inflammation, occur- 
ring in a low state of the system,' you propose to apply a certain number 
of leeches over the inflamed organ, they say no ; but they have no hesi- 
tation in applying a large blister, leaving it on until it produces full vesi- 

I injected in the same manner, and with the same result. The injection passed along the 
anterior tibial artery, through all the vessels of the foot, even with more minuteness than in the 
former instance, and, after entering the anastomosis with the posterior tibial artery, flowed 
out in a retrograde direction at the inner ankle, from the remote extremity of the aperture 
produced in that artery by the ulcerative process. Both these preparations I have preserved 
and placed in the Museum of the Royal College of Surgeons in Dublin. Why did not the 
blood impelled by the heart of this man flow into all these open vessels with the same readi- 
ness as the injection, seeing that there was no coagulum or other mechanical cause to impede 
its entrance 1 Why was there hemorrhage from the open though dead mouth of the posterior 
tibial artery, when the injection found egress therefrom with so much facility ! The answer 
is obvious : the life of the part being extinguished, the vital attraction, by which the blood was 
induced to enter, had ceased to operate, and that fluid had deserted the vessels; the heart, with 
all its power, was not competent to overcome this negative obstacle. And that the heart of 
this individual had not, by his long illness, suffered any diminution of power, may be consi- 
dered as proved by the occurrence of unusual hemorrhage during the operation, and the 
recurrence of that hemorrhage several times after the stump had been dressed. The heart, 
therefore, even in the adult human body, is not an all-powerful agent in propelling the blood 
through the vessels ; without the presence of some vital attraction in every part, its power is 
unavailing. 

" What the action of the placenta may be, in promoting the circulation of the fetus, it is 
difficult to say ; but that this organ possesses an inherent power, a vital force of drawing in 
and ejecting again the blood which traverses its vessels, no one who has ever heard the pla- 
cental soufflet— the noise caused by the rush of fluids to the spot in which it lies— will, for a 
moment, question. This rush of blood cannot be accounted for by a reference either to the 
force of the heart of the mother, or of that of the infant: it is independent of both, and due, 
no doubt, to the vital endowments of the organ itself, and of the uterus to which it is connected. 
And it is quite possible to understand that, with such vital properties in the placenta, together 
with others of a like character, co-existing in the fetus, the circulation may be carried on be- 
tween them, without any other influence whatever. Such would, at all events, be a much 
more intelligible explanation of the cause of the circulation in monsters without heart, than 
that which refers the phenomenon to the heart of a remote and disconnected fetus— an expla- 
nation which involves many contradictions and difficulties." 

In the above paper Dr. Houston has, I think, clearly established the fact, that the circulation 
through the capillaries is completely independent of the heart's influence. This opinion, 
though opposed by Muller, appears to be daily gaining ground. " Treviranus, Carus, Doel- 
lenger. and Oesterrheicher have adopted the opinion of Keilmeyer, that the blood is endued 
with a paver of self-propulsion, which they suppose to be exerted in the capillaries during 
life, independently of the heart's action, and to continue after the latter has ceased. This 
opinion seemed to be confirmed by the observations of Wolff and Pander, who asserted that in 
the chick, blood is formed in the area vasculosa, and moves from the periphery towards the 
heart, before that organ has pulsated."— Mailers Physiology, page 235. 

The reader will perceive that both Dr. Houston and the distinguished physiologists just 
mentioned, agree in the main point, viz., that the circulation through the capillaries is entirely 
independent of the heart's action— the former gentleman is disposed to attribute this to a vital 
attractive property of these vessels, whilst those last named consider it as the consequence of 
an automatic movement of the blood itself— a doctrine not easily understood. 

It affords me much pleasure to observe that Dr. Carpenter, the distinguished physiologist, 
considers the case related by Dr. Houston, as quite conclusive. See Cahpester's Principles 
of Human Physiology, page 414. 



86 CLINICAL MEDICINE. 

cation, and thus abstracting a considerable portion of white blood from the 
system. 

You will not expect me to lay down any general rules for the use and 
application of blistering in fevers ; you will find all these matters suffi- 
ciently explained in your books and manuals, I am not giving any thing 
like a regular outline of the treatment of fever ; in fact Ipass,/?er saltum, 
from one point to another, without any attention to order or method. You 
can read methodical treatises, and then compare them with such detached 
observations as I shall make. And here allow me to make some cursory 
remarks on that peculiar state of the brain which we most commonly ob- 
serve in the middle stage of typhus, and in which blisters form one of our 
most efficient, and in some instances our only mode of relief.' In many 
of the cases of typhus which come under our observation in hospital, we 
frequently meet with a train of symptoms strongly calculated to perplex 
and puzzle, and which should seldom exist in fever regularly treated ; 
these are chiefly cases which are admitted in the middle or latter stage of 
the disease, and at a period when the patient's state of intellect is such 
as to preclude the hope of obtaining any satisfactory information from a 
personal examination. 

A man in the lowest class of life, and at a distance from medical aid is 
attacked with fever ; for the first eight or ten days he is either improperly 
treated or altogether neglected, and in this state symptoms arise and super- 
induce others, causing the most unfavourable complications, and render- 
ing the cure difficult, if not impossible. Now of all the symptoms which 
occur in cases of fever, where the state of the principal organs has been 
neglected, there are none more formidable, or more fatal, than the cere- 
bral ; nor is there any local affection in fever, in which the value of pre- 
vention is so unequivocal and decided. What I wish to impress upon you 
is, that you should always anticipate the cerebral symptoms in fever. 
Never allow the cerebral symptoms to explode — watch the first scintillas 
of cerebral excitement — repress the commencing mischief, and do not 
permit your patient to be overtaken by formidable inflammation of the 
brain. Every writer will tell you that when the patient's face is flushed, 
his eyes suffused, and when he complains of headache and intolerance of 
light, you should leech and blister his head, give him purgatives, tartar 
emetic, James's powder, and the medicines calculated to bring down 
cerebral excitement: but a careful and observant practitioner will anti- 
cipate all these symptoms, although there is as yet no particular flushing 
of the face, headache, or suffusion of the eyes ; and though the patient is 
still quite rational, he will recognise threatening disease of the brain, and 
take proper steps to prevent its increase. Watch the functions of the 
brain attentively, and they will inform you, in almost every case, of the 
approach of cerebral symptoms. You will find in patients who are about 
to have cerebral symptoms, a degree of restless anxiety, and a higher de- 
gree of energy than accords with their condition ; and they either do not 
sleep at all, or their sleep is broken by startings and incoherent expres- 
sions. When you speak to a person in this state, he answers in a per- 
fectly rational manner ; he will tell that, he has little or no headache ; and 
were you to be led away by a hasty review of his symptoms, you would 
be very likely to overlook the state of the brain. If you inquire closely, 
you will find that he scarcely ever sleeps or even dozes — that he is irri- 
table, excitable, frequently incoherent, and muttering to himself. Under 



FEVER. 87 

such circumstances, although there is no remarkable heat of scalp, suffu- 
sion of the eye, or headache, I am frequently led to suspect the superven- 
tion of cerebral symptoms, particularly about the ninth or tenth day of the 
(ever (for it is generally about this period that cerebral symptoms begin 
to manifest themselves) ; and whenever I observe these premonitory in- 
dications, I neverhesitate in taking proper measures to anticipate the evil. 
I immediately order the hair to be shaved off', and blister the whole scalp. 
Thus, at the period when disease of the brain would most probably have 
set in, I have the whole external surface of the head pouring out serum, 
or even suppurating ; and when by this treatment I have opposed a bar- 
rier to the further progress of the disease, the exhibition of a little tartar 
emetic will soon remove every trace of it. In laying down this plan of 
treatment, I have supposed that the patient has been properly treated from 
the beginning, and that the earlier symptoms of inflammatory excitement 
have been combated by bleeding, leeching, and other appropriate deple- 
tory measures. 

There is, on the other hand, an opposite state of the patient, which in 
like manner informs me that danger to the brain is at hand. In this case, 
the patient is almost continually sleeping. When you enter his chamber 
in the morning, and ask how he does, his attendant generally tells you that 
he has passed the night most favourably, and that he has slept without 
almost ever waking since your visit on the preceding afternoon. If he 
awakens to take drink, he quickly drops asleep again, and when you 
arouse him he looks rather heavy; there is some slight suffusion of the 
tunica adnata, and some appreciable congestion about the external parts 
of the face and head. Persons in this state, though apparently doing well, 
and even where they have been properly treated in the beginning, about 
the ninth or tenth day begin to rave, and exhibit undoubted proofs of con- 
gestion and excitement of the brain. Now, in all cases of this description 
be on your guard, and do not allow symptoms of dangerous import to 
steal on you. Here you will derive great benefit from the use of blisters. 
I was lately called to a very remarkable case of this kind, at some distance 
from Dublin. The patient slept almost constantly, and complained of no 
headache or heat of scalp. From an attentive examination of the case, 
however, I was led to predict the approach of cerebral symptoms. Observe 
this was a case of spotted fever; and in this form of fever you can predict 
the occurrence of such symptoms with a greater degree of confidence. 
The patient's pulse was 96, his tongue presenting nothing worthy of re- 
mark, his behaviour and speech rational, and his sleep almost constant. 
Recollecting, however, the period of the fever, and observing carefully 
the condition of the cerebral functions, I had his head shaved and blistered. 
Notwithstanding this precaution, his cerebral symptoms had proceeded so 
far that he subsequently got a slight attack of paralysis of the face and 
tongue, accompanied by a fixed state of the pupils, which would neither 
contract nor dilate. After having blistered his head extensively, I gave 
him the tartar-emetic solution, to the amount of one-eighth of a grain every 
second hour. These measures were completely successful in removing 
the cerebral symptoms, and I have no doubt that the active precautions 
which had been taken were the means of saving his life. 

Now there is one symptom connected with cerebral excitement in fever 
which is well worthy of your notice, as its existence is often sufficient of 
itself to give timely intimation of the approach of irritation or inflammation 



88 CLINICAL MEDICINE. 

of the brain. This is, the state of the respiratory function. In fever, the 
breathing will often announce the approach of cerebral symptoms for days 
before their actual occurrence. When, in cases of typhus, you find the 
patient's breathing permanently irregular, and interrupted by frequent 
sighing — when it goes on for one or two minutes, at one rate, and then 
for a quarter or half a minute at another rate, you may rely upon it that 
sooner or later an affection of the brain will make its appearance. You 
will frequently observe the same kind of breathing preceding attacks of 
apoplexy and paralysis, and indeed it was the occurrence of this symptom, 
in these and other cases in which the functions of the brain were deranged, 
that first drew my attention to this kind of breathing. The first time it 
engaged my attention was in a remarkable case of an apoplectic nature, 
which I sat up a whole night to watch. On recollection, I found that I 
had frequently observed an analogous state of the respiratory function in 
fever, on several occasions, although its connection with excitement of the 
brain had not struck me before. I speak here of irregularity of breathing, 
independent of any pectoral affection. But when the patient breathes in 
a permanently irregular manner, at one time at a certain rate, and at ano- 
ther at a different rate, — when the respiration is suspicious and heaving, 
without any disease of the chest or great debility, — you will have some 
grounds to suspect the existence of cerebral derangement. I am in the 
habit of calling this kind of breathing cerebral respiration, because my ex- 
perience has told me that it is almost invariably connected with oppression 
and congestion of the brain. To recapitulate: — When you find a patient 
in fever lying constantly awake, or when, on the contrary, you find him 
continually slumbering, — when there is a certain quickness of manner and 
irritability, — and when the cerebral respiration has been noticed for some 
time without any concurrent debility orpulmonary disease, — under such cir- 
cumstances, you may, in cases of maculated typhus, predict the approach 
of cerebral symptoms; and the period about which they generally mani- 
fest themselves, is the eighth, ninth, or tenth day. Now, in cases of this 
description, — if you have previously used leeches and antiphlogistics to a 
sufficient extent, — your best plan will be to shave and blister the whole 
scalp. Dr. Little, of Belfast, and Mr. Kirby, of this city, have fallen into 
the same train of ideas, and employ blisters at a very early period of the 
disease, with the view of combating cerebral excitement. In a recent in- 
stance, in private practice, I think I saved the life of a young gentleman 
in Harcourt-street by extensive blistering of the scalp on the fourth day 
of fever. We were not accustomed to blister at this early period of fever. 
Formerly it was the practice to bleed and apply leeches for several days 
together, and never to have recourse to blistering until towards the latter 
stage of the disease. In common inflammation, or in arachnitis, we do 
not blister until we have carried depletion by the lancet, leeches, and pur- 
gatives, as far as the patient's strength will allow. But this is not the 
case in fever: the cerebral congestion and irritation, or inflammation (call 
it which you will), which accompanies typhus, differs essentially from or- 
dinary arachnitis or encephalitis, and.requires very often a treatment strik- 
ingly different. 

One physiological fact connected with sleep may be noticed here. It 
has been stated by Mr. Mayo, that the pupils are contracted during sleep. 
This is in itself a very curious fact, and I, was anxious to verify it. Now 
we had an excellent opportunity yesterday morning of trying what the 



FEVER. 89 

state of the pupil was in two patients who lay soundly sleeping in the fever 
ward. We came up softly to them as they lay on their backs, and in a 
most favourable situation for observation, just opposite one of the windows; 
and having opened the eyelids, found that the pupil was actually con- 
tracted to the size of a pin-hole. It remained in this state for a while, and 
then expanded, when they awakened. This is a very curious fact, and 
appears to be a very beautiful instance of the protective care of nature. 
To protect the eye while we sleep, nature, as it were, draws the curtain, 
and thus defends the delicate organ from any accidental dazzling, at a 
period when consciousness slumbers, and is off its guard. 

Blisters applied extensively to the shaven scalp, are not only valuable 
in fever, but also in other diseases, and that under circumstances in which 
little benefit could be expected. The same effects may be produced by 
rubbing the whole scalp with tartar-emetic ointment; but from the pain 
and inflammation it produces, this proceeding is seldom adopted. I have, 
however, occasionally employed it ; and on two recent occasions with the 
most fortunate results. A friend of mine had lost two children from hy- 
drocephalus. About five weeks ago another child, an extremely fine boy, 
was attacked with symptoms of the same disease. After having laboured 
for a fortnight under fever, with great restlessness, vomiting, and diarrhoea, 
he was observed to utter frequently that faint cry which is so characteristic 
of hydrocephalus, and to roll his head constantly from side to side. These 
symptoms were soon afterwards succeeded by constant motions of the right 
arm and leg, and subsequently by paralysis of the opposite side. I was 
consulted before the paralysis occurred, and advised the child's father to 
have the whole of the blistered scalp well rubbed with tartar-emetic oint- 
ment. The boy recovered completely. I derived also a very striking 
advantage from the use of the same remedy in a very remarkable epidemic 
which attacked a family in the neighbourhood of Rathmines, and which 
was witnessed throughout its whole course by my friend Dr. Burke and 
myself. One of the family, a young lady, was attacked with symptoms 
of fever, accompanied by a pain in the back of the head, and stiffness of 
the neck. x\fter a few days, symptoms of inflammation of the cerebellum 
and upper part of the spinal cord became developed. About the seventh 
day she got strabismus, and soon afterwards was attacked with convul- 
sions: the pupil became permanently dilated, and she was quite blind. I 
was called to see her at this period, and found her almost in a state of in- 
sensibility, with involuntary discharge of urine and feces, cold extremi- 
ties, and irregular pulse. Thinking that nothing could be done for her, 
I was about to leave the room when I asked the nurse, could she swallow? 
She replied she could, and immediately proceeded to offer the young lady 
some drink, which she swallowed without any difficulty. This at once 
arrested my attention. I said to myself, if this patient can swallow, she 
must be still conscious, and while she is so, there is a chance of saving 
her. I ordered the whole of the scalp, which had been previously blistered, 
to be rubbed with tartar-emetic ointment; violent inflammation ensued, 
and she recovered completely. But the curious part of the case is this: — 
her brother and sister were attacked, in exactly the same way, a few days 
afterwards, although less formidably, and were cured by the same treat- 
ment. Shortly afterwards two of the servants got pain in the back of the 
head and stiffness of neck, followed by signs of an inflammatory affection 
of the cerebellum and spinal cord. They were treated in the same way, 
and recovered. 



90 CLINICAL MEDICINE. 

What could be the cause of this peculiar fever, manifesting itself in ex- 
actly the same way in all the individuals of the family who were attacked? 
I endeavoured to arrive at the cause, but could not; and I merely state 
the facts, without wishing to attempt any thing like an explanation. But 
the history of this extraordinary form of disease is exactly as I have told 
you. It has been witnessed by Mr. King and Dr. Burke, and they, as 
well as myself, were very much struck with the novelty of the phenomena. 



LECTURE VIII. 

Further remarks on the treatment of Fever — Management of delirious patients — Advantages 
of tartar emetic in the form of enema — Subsultus tendinum sometimes from disturbance of 
the nervous extremities, independently of the brain or spinal cord — Vomiting and purging 
at the commencement of fever, indicative of cerebral affection — Scrofulous inflammation of 
the brain — Chronic scrofulous fever. 

In speaking of the use of drinks in fever, I alluded to the abuse of soda 
or seltzer water, and effervescing draughts. It is very much the custom 
both in hospital and private practice, to look upon the latter as a remedy 
which may be administered at the pleasure of the patient, or the discretion 
of the nurse. They are certainly to many persons a most grateful means 
of cooling thirst; but the cautious physician will never allow his patient 
to indulge too much, for he knows that their frequent use distends the 
stomach, and produces a tendency to tympanitis, and bowel complaint. I 
am also of opinion that the exhibition of large quantities of free carbonic 
acid is a very doubtful, if not a dangerous, practice in fever, and may in- 
crease that tendency to narcotism and functional derangement of the ner- 
vous and respiratory systems, which is observed in every case of genuine 
typhus. In addition to this, the evolution of a large quantity of fixed air 
in the stomach frequently causes a very disagreeable sense of distension 
and suffocation, and acts injuriously on the mucous membrane. 

Allow me here to digress a moment from my subject, and make a few 
observations on a case which terminated fatally in our wards within the 
last twenty-four hours. I wish to call your attention to this case more 
particularly, as I think a different plan of treatment might have succeeded 
in saving the man's life. This man was admitted into the fever ward 
about the seventh or eighth day of his illness. I cannot exactly state how 
he was treated in the commencement, but I believe he was very badly 
attended, and that the state of the principal organs was wholly neglected. 
It will be sufficient to state, that when he came under our care the chief 
features of his case were delirium, accompanied by total want of sleep, 
and a violence of conduct and behaviour calling for the restraint of the 
strait waistcoat. Now under circumstances of this nature the most diligent 
attention and promptitude are imperatively demanded on the part of the 
physician, and every step calculated to anticipate danger should be 
instantly taken. I regret to say that I did not at the time take a correct 
view of the treatment, or precautions necessary to be adopted under such 
exigencies. I did not expect that the case would terminate fatally in 
such a short time, and I anticipated benefit from the remedy prescribed. 
He was ordered to take the tartar-emetic solution in full doses ; but on 



FEVER. 91 

visiting him next morning, we found that he had obstinately refused to 
take his medicine, and that his symptoms were greatly aggravated. 

In delirium of this kind it is certainly very difficult to manage the 
patient, and we are frequently obliged to have recourse to force and 
stratagem to make him take his medicines. I regret extremely that this 
man's head was not leeched on his admission, as, from the state of his 
pulse, I think he would have borne it well. Eight leeches might have 
been applied to his temples, and repeated two or three times the same 
day, according to the state of pulse and strength. I think I was wrong 
in contenting myself with ordering the tartar-emetic solution and a blister 
to his head, and [ should have anticipated from the violence of his 
behaviour that it would be very difficult to manage him. 

In cases of this kind, where it is necessary to give tartar emetic (and 
this is one of the best remedies you can employ in cases of cerebral 
excitement in fever), you should be always prepared to obviate any 
omission arising from the obstinacy of the patient ; and when he will not 
take his medicines voluntarily, you may secure its effects on the system 
in two different ways. In the first place, it may be secretly mixed with 
the patient's ordinary drink ; and as such persons are generally thirsty, 
and seldom refuse drink altogether, an intelligent nurse will readily find 
means to make the patient take a sufficient quantity of it to secure its full 
effect on the cerebral circulation. 

Another expedient which you may resort to on similar emergencies, is 
to give the tartar emetic in the form of enema. I had recourse to this 
plan some time since, in a similar case of delirium, and with the best 
results. After leeching the head I gave the solution of tartarized antimony 
in enema ; and this can be always done, whether the patient likes it or 
not, if you take care to prevent his struggles by confining him in a strait 
waistcoat. The best way of administering it is to dissolve two or three 
grains of tartar emetic in four or five ounces of mucilage of starch or 
isinglass, and inject it with the aid of a long flexible tube, so as to make 
the contents of the syringe pass high up into the bowel. In this way you 
can secure all the good effects of tartarized antimony in overcoming the 
congestion of the brain, and procuring sleep. In all cases of alarming 
congestion of the head in fever, I have been long in the habit of using 
tartar emetic in this way, if the stomach be deranged, and incapable of 
bearing it safely ; and I can assure you that it is a most fortunate thing to 
have such a powerful resource in all cases of the kind. I have also not 
unfrequently given expectorant medicines in the same way, where from 
the state of the stomach, or the debility of the patient, the ordinary remedies 
could not be administered by the mouth with sufficient rapidity, or in 
sufficient quantity to produce the desired effect. In this manner I have 
often given the infusion of ipecacuanha — a remedy of very considerable 
value, and not sufficiently appreciated by most modern practitioners. I 
may also remind you that vomiting, and all the benefits derivable from 
it, may be likewise thus produced. Of course the cases in which these expe- 
dients are required are comparatively rare, but the practical physician 
must be always prepared for such exigencies, and be provided with means 
of meeting them. 

Another of our patients died also within the last few days in the fever 
ward. He laboured under a very bad form of maculated fever, and when 
admitted was evidently in a hopeless state. I shall not say any thing 



92 CLINICAL MEDICINE. 

about this case, except to use it as an occasion for making a few observa- 
tions on a particular state of the cerebro-spinal system, which we not 
unfrequently observe in cases of maculated typhus, and occasionally in 
other varieties of fever. Now you observed that this man had not the 
slightest tendency to sleep ; that he lay with his eyes constantly open, 
raved incessantly, had subsultus tendinum, floccitatio, and cold extremi- 
ties, and often attempted to get out of bed. Yet we could not find in him 
any thing like decided evidence of cerebral inflammation, The tunica 
adnata was of a clear pearl-white, the face pale, and the scalp and integu- 
ments of the face cool. You perceive, then, that sleeplessness, delirium, 
and subsultus tendinum, may depend on a state of the nervous system 
having no connection with congestion of the brain, or determination of 
blood to the head. This occurrence has struck me very forcibly in many 
cases of fever. But I have been most particularly struck with the occur- 
rence of subsultus tendinum in such instances. In the present case we 
had a patient with sleeplessness and subsultus. But this concurrence of 
symptoms does not always exist. You recollect the case of the boy in 
the small fever ward, who laboured under excessive subsultus, and to 
whom we gave the spirit of turpentine in drachm doses with so much 
benefit. Yet this boy, as you all remember, slept remarkably well. I 
have frequently pointed out to the class patients labouring under subsultus 
tendinum, who slept well, and in whom the tunica adnata was of a pearl- 
white colour, without the slightest suffusion. We have subsultus, there- 
fore, occurring in two very opposite states of the nervous system ; we have 
it accompanied with loss of sleep, and we have it existing in that condition 
of the system where the patient slumbers long and heavily, and cannot be 
easily roused. Hence I was inclined to think that the cause of subsultus 
resides not so much in the nervous centres as in their extremities. I 
would even go so far as to advance the proposition, that if it were pos- 
sible for the fever to go on, and life to continue after the removal of the 
brain and spinal cord, I am quite sure that the subsultus would continue. 
I am almost confident that subsultus tendinum is the result of some 
derangement of the nervous extremities. I have shown on a former 
occasion, when lecturing on the subject of paralysis, that the nervous 
periphery may become diseased primarily, and without any antecedent 
affection of the brain or spinal cord. I think it extremely probable that 
in fever the nervous centres are subject to certain derangements producing 
coma, sleeplessness, and delirium, but that there are other nervous symp- 
toms which are to be referred rather to a derangement of the nervous 
extremities, and among the latter I would particularly include subsultus 
tendinum, a symptom which we find co-existing with such opposite con- 
ditions of the nervous centres. 

But to return to the case to which I first alluded. Never blister in the 
early stage of fever, until you have applied leeches in sufficient quantity. 
In this case, it is true, we could not well ascertain what the period of the 
fever was ; for the man was brought in in a state of delirium, and there 
was nothing known respecting his previous history. Yet you are all aware 
that a great deal must depend on our knowledge of the period of the fever, 
and the medicines which have been employed. Had we been acquainted 
with these circumstances, it is probable we would not have fallen into 
the error we committed. What I wish to impress on you is, that in all 
cases of maculated typhus, you should be careful in examining the head 



FEVER. 93 

and ascertaining whether there are any evidences of cerebral congestion 
present. If there is headache, strong pulsation of the carotids, suffusion 
of the eyes, and heat of the face and scalp, along with the other signs of 
functional lesion of the brain present, you should always have recourse to 
leeching; beginning cautiously, and continuing their application as long 
as the patient will bear it with safety. When you have the symptoms 
already mentioned, and the patient is in the early stage offerer, you may 
commence by applying one or two leeches to the nostrils, or six or eight 
to the temples, or behind the ears, repeating them two or three times 
a-day, according to the exigency of the case. The best way of using 
leeches is to apply them in small numbers every six or eight hours, so as 
to keep up a constant drain from the head. After you have leeched suf- 
ficiently, you may then have recourse to blisters. In making this change 
much will depend on the sagacity and .skill of the practitioner; for it 
requires no ordinary tact to hit on the proper time when you should give 
up leeching and commence with blisters. 

I shall make no apology for introducing here what I consider to be an 
important observation, with reference to the pathology and treatment of 
fever. We had a striking instance of the fact on which I am about to 
offer some comments, in the case of a little girl who died lately here, in 
a very remarkable manner. I mentioned in a former lecture, that vomit- 
ing and purging in the commencement of fever are, generally speaking, 
indicative of a cerebral affection. Every fever which commences with 
vomiting and diarrhoea, whether it be scarlatina, or measles, or typhus, is 
a fever of a threatening aspect ; and in all such fevers the practitioner 
should be constantly on the watch, and pay the most unremitting attention 
to the state of the brain. There is much difference between the vomiting 
and diarrhcea of gastro-enteritis, and this cerebral diarrlura and vomiting. 
The latter sets in generally at a very early period of the disease, perhaps 
on the first or second day, and is seldom accompanied by the red and 
furred tongue, the bitter taste of the mouth, the burning thirst, and the 
epigastric tenderness, which belong to gastro-enteric inflammation. There 
is also another source of diagnosis, but of a less valuable kind ; and this 
is founded on the results of treatment. Gastro-enteric vomiting and diar- 
rhoea are relieved by leeching the belly ; but I need not tell you that this 
mode of treatment can have no effect on the vomiting and purging pro- 
duced by cerebral disease. There is also another means of distinguish- 
ing : the vomiting and diarrhoea which result, from gastro-enteric inflam- 
mation is never accompanied by such copious discharges of bile as that 
which depends on disease of the brain. In diarrhoea from derangement 
of the brain, the quantity of bile passed is very remarkable ; and it is 
equally curious, that when vomiting follows derangement of the cerebral 
circulation, in ordinary cases, and without fever, bile is thrown up in 
very large quantities. This is frequently observed in persons who become 
sick from swinging or sailing. In such instances, a larger quantity of 
bile is vomited than could occur from mere gastric irritation. Now in 
the commencement of cerebral disease, where congestion or inflammation 
is present, one of the first symptoms is copious vomiting, and purging of 
a bilious character. This is very often the case in scarlatina, and there 
are few cases in which there is more danger to be apprehended. W r e 
had these symptoms, under very unfavourable circumstances, in the little 
girl to whom I have just alluded. From the imperfect history of the case 



94 CLINTCAL MEDICINE. 

which we were able to obtain, it appeared that she had been ill of fever 
for fourteen days before her admission, and had in addition a severe attack 
of bronchitis and pneumonia. She then got inflammation of the stomach, 
and finally congestion of the brain, as indicated by the cerebral vomiting 
and purging. We employed every means in our power to check these 
symptoms, but without success ; she went on from bad to worse, and she 
ultimately sank under a combination of affections, which you will fre- 
quently observe in many forms of disease as well as in fever ; and it is to 
this point in particular that I wish to direct your attention. You will 
frequently observe that at a certain period of fever, whether it be inflam- 
matory, nervous, bilious, or typhoid, — and very often in other forms of 
disease, whether depending on a general affection of the system, or con- 
nected with inflammation of important organs, when the patient has been 
going on pretty well for same time, — you will find that about the period 
when you would naturally expect that the fever would go off, and conva- 
lescence begin, a new form of fever makes its appearance, and carries off 
the patient in spite of all your exertions. To this form of secondary fever 
I would give the name of scrofulous, because it resembles in its chief fea- 
tures the intractable form of fever which is frequently observed in persons 
of an originally scrofulous habit, or who have become so from" the abuse of 
mercury or other debilitating causes. This is a subject which is not well 
understood, and I am not acquainted with any author who has devoted to 
it that share of attention to which, from its great importance, it has such 
decided claims. Its chief characters are, that the patient, during its 
existence, exhibits a strong tendency to inflammatory affections, which 
bear a close analogy to the scrofulous, both in their intractable character, 
in the facility with which they pass from one organ to another, and in 
their frequently unfavourable termination. A patient of this description, 
while labouring under fever, will frequently exhibit a very remarkable 
succession of inflammatory affections. If, during the course of his fever, 
he gets an attack of gastro-enteritis, you will have great difficulty in 
managing it ; and no sooner is this overcome, than he is seized with bron- 
chitis or pneumonia ; and when, by great care and the most skilful treat- 
ment, you have overcome this also, he gets scrofulous inflammation of 
the brain, and dies. Now you will frequently meet with patients who, 
during the course of typhus, will be attacked with this bad form of fever, 
and get what may be termed scrofulous inflammation of the brain, which 
carries them off in five or six days, in spite of all your care. You are 
aware that persons who are much in the habit of observing diseases of the 
brain, can generally distinguish between scrofulous inflammation of the 
brain and its membranes and that inflammation which occurs in persons 
of healthy habit. In cases of the latter description, the treatment, if 
commenced at the first appearance of the disease, is simple and success- 
ful. Appropriate bleeding and leeching, with the use of calomel and 
James's powder, are almost always sufficient to accomplish a cure. 
When once you have succeeded in touching the gums with mercury, the 
patient's safety is tolerably certain, and recovery is in general rapid ; but 
in the scrofulous affections of the brain, though you may have fully mer- 
curialized your patient, you will too often discover that you have merely 
retarded the progress of the complaint for a brief period ; it grows bad 
again, and carries him off in spite of all your efforts. In the scrofulous 
hydrocephalus, a much greater time elapses from the appearance of coma 



FEVER. 95 

and strabismus until death takes place, than in the ordinary forms of 
meningitis. This fact was well illustrated in the case of the girl to which 
I have just now referred : she continued to live on for a long time after 
the appearance of symptoms which you would think ought to terminate 
fatally in a few hours after they had been developed. There is also a 
great deal of irregularity in the way the symptoms come on in cases of 
scrofulous inflammation of the brain. Sometimes blindness is one of the 
first symptoms. I recollect having been called, with Dr. I3eatty,to see a 
very fine boy, living in Merrion Square, and was very much struck, on 
entering the drawing-room, to find him walking about, and in apparent 
good health, but quite blind. Here amaurosis was the first symptom. 
This was subsequently succeeded by others, and he died in a convulsive 
fit about a fortnight afterwards. 

We have many excellent observations on the chronic scrofulous fever, 
but I think that there is no author who has described this acute form with 
the precision and care which it deserves. It is, however, a very frequent 
form of fever, and you will see many examples of it among the chronic 
patients in the medical and surgical wards. You will frequently observe 
persons who are labouring under acute disease, from accidents or other 
causes, become feverish and ill again at a time when you expected a re- 
mission of their symptoms, or even recovery ; and without any assignable 
cause, they will get scrofulous inflammation of some other part or organ, 
and quickly fall into a state of hopeless and incurable disease. 



LECTURE IX. 

Morbid appearances after Delirium in Fever — Treatment in anticipation of Cerebral symptoms 
— Great advantage of Blisters judiciously employed — Notice id' the old mode of Blistering. 

I spoke at my last Lecture of a man named Ca-sels, who died in the 
fever ward with symptoms of cerebral excitement, and stated that I re- 
gretted having omitted to leech his bead, and prescribe tartar emetic in 
the form of enema. Since that time we have had an opportunity of 
examining his body, and the results of the dissection are well worthy 
your attentive consideration. He was a young man of robust habit and 
apparently good constitution, and laboured under the ordinary form of 
maculated typhus. Shortly after his admission he was attacked with deli- 
rium, which was soon afterwards followed by coma and death. Now, 
suppose you were called to see a patient, not labouring under typhus, but 
exhibiting a similar train of symptoms — that is to say, violent delirium, 
accompanied by flushing of the face, suffusion of the eyes, headache, and 
a tendency to get out of bed — in fact, a state of furious excitement requir- 
ing the restraint of the strait waistcoat — what idea would you be likely 
to form of the condition of the brain ? If a patient of this kind had no 
typhoid symptoms, you would certainly say that he was labouring under 
meningitis or cerebritis ; and if the case proved fatal, you would naturally 
expect to find lesions of the brain fully sufficient to account for all his 
symptoms. And you would in all probability find extensive thickening 
of the membranes of the brain, with subarachnoid effusion, or you would 
discover softening, increased vascularity, and suppuration of the ence- 



96 CLINICAL MEDICINE. 

phalic mass. But, here, a man in fever exhibits all the symptoms of 
cerebral inflammation ; the cerebral affection runs on to a fatal termina- 
tion with great rapidity ; he dies comatose. And what do we find on 
dissection ? Doubtful signs of congestion, and no distinct evidence of 
inflammation ; a slight opacity of the arachnoid at the base of the brain, 
and about a teaspoonful of clear subarachnoid effusion. Now this is a 
point to which I would earnestly call the attention of every inquiring stu- 
dent. A patient, during the course of typhus, is seized with symptoms 
which are generally regarded as characteristic of congestion and inflam- 
mation of the brain ; he dies, to all appearance in consequence of the 
intensity and violence of these symptoms, and on dissection little or no 
trace of cerebral disease is found. In the case under consideration, the 
symptoms present were strongly indicative of congestion if not of inflam- 
mation ; and had the man been free from typhoid symptoms, you would 
expect to find decided traces of inflammatory mischief. This seems to 
prove that in the production of cerebral symptoms in typhus, some cause 
not to be recognised by the production of cerebral lesions, or in other 
words something besides mere congestion or inflammation exists. I have 
now examined a great number of cases of this description, and the exami- 
nation has brought home to me a strong conviction, that the delirium of 
fever depends upon something more than mere inflammation or conges- 
tion. There is another fact, the study of which is well worthy of atten- 
tion, as it appears to support very strongly the views I have put forward ; 
and that is the occurrence of analogous symptoms under opposite conditions 
of the cerebral circulation. Take, for example, the phenomena of ver- 
tigo and headache. Now these symptoms are found in states of the brain 
w T hich are directly opposite. In incipient congestion of the brain, in that 
turgescence of the cerebral vessels which precedes apoplectic seizures, 
one of the most frequent symptoms is vertigo, and the same thing may be 
affirmed with respect to headache. But we observe the very same symp- 
toms under circumstances totally dissimilar. Frequently while bleeding 
a patient for some affection of the lungs or bowels, or for some accident, 
we find that after a certain quantity of blood has been lost, the patient 
becomes pale ; and while the pallor is coming on, he often gets quite 
giddy, and sometimes complains of headache. Gentlemen who are 
attending lying-in hospitals are well acquainted with the headache, giddi- 
ness, and tinnitus aurium, so constantly complained of by females who 
have suffered from excessive uterine hemorrhage. Hence you perceive 
facts are not wanting to show that opposite states of the cerebral circula- 
tion, a superabundance or deficiency of pressure on the brain, may give 
rise to similar phenomena. You saw an illustration of this in the case of 
one of our patients in the fever ward this morning. He was quite free 
from headache as long as he remained in the horizontal posture, but the 
moment he sat up in bed he complained of headache. Yet this was a 
man who had not the slightest symptom of determination to the head, 
and who had been sufficiently depleted during his illness. You will also 
recollect the fact, that persons who have had a long illness, and remained 
for many days in the horizontal posture, generally get weakness, giddi- 
ness, and sometimes headache, at first when they attempt to sit up during 
convalescence. This is a point which should always be borne in mind. 
You are consulted by one person who complains of giddiness, tinnitus 
aurium, and frequently recurring headache. You examine the patient 



FEVER. 97 

carefully, and you find all the symptoms of unequivocal determination to 
the head. You are applied to by another person labouring under the 
same symptoms ; but how different is the state of the brain found to be on 
a careful examination. One patient is robust, of florid complexion, and 
with a hard bounding pulse ; the other is a weak chlorotic female who 
has been ailing for months, and whose pulse is so weak, that a slight 
degree of pressure obliterates the canal of the artery. Yet the tinnitus 
aurium, giddiness, and headache complained of by the latter, are just as 
bad and as troublesome as in the case of the former. 

From a consideration of these points, you will perceive that, for the 
production of cerebral symptoms in typhus, there must be something more 
than mere congestion or inflammation of the brain ; but you are not to 
infer from this that there is no necessity for taking any steps to obviate or 
remove congestion of the head in fever. On the contrary, I am of opinion 
that in typhus one of the principal sources of danger is connected with 
the head, and that the cerebral symptoms should be always watched with 
the most unremitting and anxious attention. It is this which constitutes 
the great difference between the mortality in private and hospital practice. 
In private practice the physician is called at an early period of the disease, 
and has an opportunity of checking the cerebral symptoms before they 
rise to a dangerous height ; but hospital patients, in general, are admitted 
at an advanced stage of fever, and in many instances have been improperly 
treated, or wholly neglected from the commencement. I am also of 
opinion, that when there is any evidence of determination to the head, 
the best way of preventing dangerous cerebral symptoms is to deplete the 
head by the application of a sufficient number of leeches, and then to 
proceed to the use of blisters. You should direct your attention as much 
to the head as to the bowels, and one of the best modes of doing this is 
to apply six or eight leeches behind the ears, and repeat them every six 
hours until relief is obtained. You should then order the head to be 
shaved, and kept constantly covered with cloths wet with warm vinegar 
and water, and at the same time have recourse to the internal use of tartar 
emetic and nitre, or blue pill with James's powder. Should this plan fail 
in giving relief, you have a powerful aid in the application of blisters to 
the scalp, and this must be done extensively, and at once. 

Most of the fatal cases of typhus at present die of cerebral disease.* 
But in the majority of instances you will find that these were cases in 
which the head was neglected, and in which the appropriate remedies 
were used too late. In cases treated from the commencement with judg- 
ment, decision and attention, although the head may be threatened, you 
will not have one-twentieth of the mortality observed in cases where the 
early prevention of cerebral symptoms has not been an object of care. 
One of the worst cases of cerebral disease which I have witnessed for 
many months, and which would have probably terminated fatally before 
the seventh day, I saw in consultation wit Mr. Daly, and yet this case 

* [In the genuine typhus fever this is almost always the case. Very few 
patients die of this disease without strongly marked cerebral symptoms, 
but we do not on that account find strongly developed cerebral lesions ;. 
on the contrary the brain is generally found in a condition but little dif- 
ferent from that of health, and the lesions are very unlike those met with, 
in proper inflammatory affections of that organ. — W. W. G.] 
8 



98 CLINICAL MEDICINE. 

was saved by prompt and decided measures calculated to counteract the 
cerebral symptoms. I have also very recently witnessed another remark- 
able case of this description at Bray. 

The patient, a gentleman very full and plethoric, but remarkably tem- 
perate, aged thirty-five, was attacked after exposure to cold by intensely 
violent maculated fever, for which aperients of an active nature were 
exhibited. I saw him in consultation with Dr. Hefferman on the fifth 
day. His headache had been relieved by leeching, but his breathing was 
very quick, and he was almost constantly asleep. Skin very hot : eyes 
somewhat suffused ; most copious crop of maculae. We at once blistered 
the whole scalp ; and on the eighth day blistered it again, and also the 
nape. On the ninth day the cerebral symptoms, which we had been 
endeavouring to anticipate, came on, but probably our treatment prevented 
them from being fatal ; for when they appeared, the application of tartar- 
emetic ointment induced a purulent discharge from the whole surface of 
the twice blistered scalp, in the course of a few hours, and three grains 
of tartar emetic given in divided doses that day procured a complete 
cessation of the symptoms, after — mark, after — the pupils had been 
dilated, and one fit of slight paralysis of the mouth and tongue had taken 
place. 

The result of all my experience in fever is, that the majority of fatal 
cases are rendered so, in this country at least, by severe cerebral symp- 
toms supervening sooner or later in the disease. Delirium, sleeplessness, 
stupor, convulsions, extreme subsultus, jactitation, sluggish and dilated, 
or else extremely contracted, pupils : these are the symptoms we have to 
fear after the fever has lasted some time; and let me repeat it, the chief 
;art of the physician consists not so much in remedying these symptoms as 
;in anticipating them. When he judiciously attempts this, he may not, 
indeed, always succeed in preventing their supervention, but he will, in 
many cases, be successful in diminishing their violence, and preventing 
their usual disastrous effects. 

I shall now resume the subject of blistering in fever, on which I made 
some observations in my last lecture. I have spoken of it chiefly as a 
powerful revulsive remedy in the treatment of cerebral congestion ; let 
us now treat of its employment with other objects in view. In the first 
place, as has been already explained, blisters may be used as most energetic 
stimulants in cases where the powers of life flag, and threaten a sudden 
cessation. Occasionally, in fever, you will find the vital tone reduced 
to a very low pitch, the heart uncertain in its action, the pulse irregular, 
the respiration feeble, the skin cool, and the patient so weak that he 
cannot be lifted up, or even turned in bed, without having a tendency to 
faint. Here w r e have to superadd to the ordinary treatment of fever the 
prompt exhibition of remedies calculated to meet such emergencies, and 
in addition to internal stimulants, we have recourse to powerful stimula- 
tion of the cutaneous surface by what are termed flying blisters. One of the 
best remedies in such cases is a large blister applied over the region of 
the heart, to be left on for two or three hours, or until the vascular action 
of the skin is sufficiently excited. When the patient appears to labour 
not only under sudden weakness of the heart, but also of the capillary and 
nervous systems, as shown by coldness of the extremities and sinking of 
the pulse, it will be necessary to apply flying blisters, not only over the 
region of the heart, but also over various parts of the chest, the epigas- 



FEVER. 99 

trium, and the inside of the legs and thighs. You will find this plan of 
treatment frequently succeed in cases which have a very unpromising 
aspect. I have now witnessed many instances of this description, in 
which, from cold, neglect, or debilitating treatment, the patients appeared 
moribund, with lividity of the extremities, hippocratic face, cold skin, 
and failing pulse ; and I have seen them saved, as it were miraculously, 
by the use of carbonate of ammonia, musk and wine, and the applica- 
tion of warm fomentations to the limbs, followed by a succession of flying 
blisters. 

The next use to which we apply blisters is in the treatment of those 
pulmonary affections which arise during the course of typhus. From 
what you have seen of the present epidemic, you must be convinced that 
bronchitis is one of its most frequent complications, and that few patients 
pass through fever without having some affection of the bronchial mucous 
membranes. You are also aware, that when bronchitis attacks the more 
minute ramifications of the bronchial tubes, it is very apt to produce con- 
gestion and engorgement of the lung. We meet with pneumonia much 
less frequently in fever, but it is occasionally observed, and requires the 
most prompt and decided treatment. In pneumonia, as well as in con- 
gestion of the lungs accompanied by inflammation of the smaller bronchial 
tubes, blisters afford us a most valuable adjunct to the other means which 
we employ, and admit of being used in cases where no other mode of 
depletion could be safely borne. The affections of the lung in fever are 
of no small importance, and the stethoscope has not conferred a greater 
benefit on practical medicine, than by indicating, in diseases of the chest, 
not merely the existence of disease, but also its locality, extent, and 
precise nature. It points out to us the portion of the chest in which the 
bronchial tubes are chiefly engaged, and informs us with certainty when 
the affection of the smaller tubes has given rise to pulmonary engorge- 
ment. The experienced stethoscopist will in such cases be aware of the 
exact site and nature of the affection, where the mere symptomatic prac- 
titioner would be unable to acquire any thing more than a loose and 
undefined notion of pulmonary disease. The latter employs his depleting 
means at random, and frequently abstracts a large quantity of blood with 
little benefit to his patient; the former, aware of the precise situation and 
extent of the disease, applies his leeches or cupping-glasses immediately 
over the engorged or inflamed portion of the lung, and relieves his 
patient at the expense of a comparatively small loss of blood. The same 
observation will apply, with equal force, to the use and application of 
blisters. A good and accurate knowledge of the various stethoscopic 
phenomena is besides of so much more value in the treatment of fever, 
as, at certain seasons of the year, almost every case of fever will be com- 
plicated with pulmonary derangement ; and it may happen, during the 
course of an epidemic, that the lungs may be the organs which are chiefly 
engaged. Although cerebral disease is at present the principal source of 
danger in fever, it may not be so always. A change may take place in 
the character of the epidemic ; the cerebral symptoms which are now of 
such frequent occurrence may become unfrequent, and we may have the 
organic affections chiefly limited to the viscera of the thorax. I have 
seen many cases of fever in which the principal source of danger was 
connected with the chest, and where an accurate knowledge of the ste- 
thoscope was indispensable to a correct and successful plan of treatment. 



100 CLINICAL MEDICINE. 

Now, when you have recourse to blisters in treating pulmonary affec- 
tions, whether these affections be simple or complicated with typhus, it 
would be well to recollect that much good may be effected without leaving 
the blisters on for a long time, or until they rise fully ; and also that when 
risen, it will not be necessary to cut them at once and let out the effused 
serum. In treating the bronchitis of children, and in the bronchial affec- 
tions of fever, I have frequently directed the blister to be left unopened ; 
and I can state, from experience, that this plan answers very well. The 
effused serum forms one of the best dressings for the excoriated surface 
of the skin, and the formation of troublesome sores is avoided. I fre- 
quently have recourse to this mode of treating blistered surfaces in 
children, and persons of irritable habit, in whom the cutis is extremely 
tender and vascular. Such persons, when blistered, will often have 
profuse discharges, first of serum and afterwards of sero-purulent matter, 
from the denuded surface, accompanied by torturing pain, loss of rest, 
and considerable irritation of the general system. I have seen the dis- 
charge continue to flow profusely for five or six days ; in fact, to such an 
extent as to wet several napkins in the course of a day, and expose the 
patient to the risk of an aggravation of the pulmonary symptoms, in con- 
sequence of his linen becoming so frequently moistened as to require 
repeated shifting.* In all cases of children and persons of an irritablehabit, 
I would therefore advise you # to let the blisters alone, particularly where 
they have been applied to the fore part of the chest, or any other part not 
exposed to pressure or friction. As soon as the blister rises, apply over 
it a piece of lint, smeared with spermaceti ointment, which can be renewed 
as occasion requires, and leave the rest to nature. I was forcibly struck 
some time since, with the difference of result between this and the ordi- 
nary practice, in the case of a young gentleman residing in Camden 
Street, who had a severe attack of bronchitis towards the termination of 
fever. A blister had been applied to his chest in the morning, and another 
in the middle of the day. The first had been opened freely, and dressed 
in the usual way ; but the other, which had risen about the time I was 
called in, was left untouched at my request. The one which had been 
opened caused such a degree of irritation and restlessness, that it was 
found necessary to give him an opiate every night ; the other gave little 
or no inconvenience, and healed up much sooner. If I have done nothing 
better, I think I deserve some merit for being the first to reprobate the 
practice of keeping on blisters for twelve, eighteen, and twenty-four hours, 
and for having shown, by numerous experiments, that a much shorter 
period of time was required to ensure the full effect of these remedies. 
When I commenced the practice of medicine, blistering was looked upon 
by most sick persons as one of the severest trials of their patience, and 
the agony which it caused in some irritable habits was almost insup- 
portable. Blisters were left on for twelve, eighteen, and even twenty- 
four hours, and when at length they were removed, the whole epidermis 
of the blistered part came, or was torn away, leaving behind a raw irri- 
table surface, from which large quantities of serum and pus were effused 

* In pulmonary diseases, this continued discharge is often very useful, and should be 
encouraged, by dressing the vesicated surface wilh the French blistering paper, or, what I have 
found equally useful, that prepared by Mr. Bewley of this city : but in fever the production of 
such effects from blisters must be avoided, as a surface thus denuded of its cuticle, and inflamed, 
may be converted into a dangerous sore. 



FEVER. 101 

for several days, to the great torture and inconvenience of the patient ; 
and, not content with this, the practitioners of that time generally dressed 
the excoriated surface with some sharp stimulant ointment, so that the 
blistered surface most commonly resembled that of a severe burn. Ask 
those who are our seniors in practice, and they will tell you what blistering 
was twenty or thirty years ago. They first produced excessive irritation 
of the skin, by leaving the blisters on too long, they then irritated the 
denuded surface with stimulant ointments, and in this way brought on 
extensive sores of a bad character, which remained long after the disease 
for which the blisters were applied had disappeared, and which formed, 
in fact, a new ailment, requiring new medicines and additional attend- 
ance. If you look over Mr. Moore's account of the principal remedies 
employed in the practice of Dublin physicians, about the period I allude 
to, you will find that nothing was more common then than the application 
of stimulant and, as they were termed, digestive ointments, to blistered 
surfaces. I was among the first who assailed this barbarous treatment, 
and showed that all the good effects of blisters might be secured by 
leaving them on for a much shorter space of time. I proved by numerous 
experiments, that in many cases it was not necessary to leave them on 
more than four or five hours, in the adult,* and that they might then be 
removed and the blistered part dressed with spermaceti ointment. Under 
this dressing the blister rises well, and there is no danger of tearing away 
the cuticle, or producing an irritable sore. In addition to this, you 
entirely avoid the irritating effects which blisters are known to produce 
on the urinary organs. You will very rarely meet with dysuria, or hema- 
turia, where the blister has been left on for the spaces of time I have 
mentioned. 

Blistering is then to be used with the restrictions I have mentioned, 
and you will find it a most valuable aid in the treatment of fever and its 
complications. It may be employed either as a derivative and revulsive, 
or you may have recourse to tlying blisters over various parts of the body, 
in certain forms of fever, where there is marked and sudden depression 
of the powers of life. 

Speaking of depression of the powers of life, reminds me of a curious 
incident which occurred some time ago in my practice, and which shows 
the value of being acquainted with the peculiar habits and idiosyncrasies 
of families. I attended, with Mr. Kirby, about three years since, a gen- 
tleman of middle age and active professional habits, who had been attacked 
with fever. I was first called to see him on the ninth day of fever, and 
found him apparently moribund. His pulse was intermittent and irregu- 
lar, the action of the heart tumultuous, the respiration feeble, and the ex- 
tremities cool. Mr. Kirby had instantly ordered internal stimulants, and 
blisters over the region of the heart and epigastrium. The patient rallied, 
and ultimately recovered. It is to be observed, that the group of formi- 
dable symptoms just enumerated had supervened quite out of the usual 
course, and without any previous warning. They were consequently not 
only alarming but unexpected. About a month afterwards, Mr. Smyly 
and I were called to see this gentleman's brother, who was living at Dun- 

* Of course blisters applied to the scalp must be excepted. They require at least twelve 
hours. In old persons generally the skin is much less vascular than during youth and middle 
age : and consequently, in the old, blisters require a much longer time to produce the required 
effect. 



102 CLINICAL MEDICINE. 

drum, and who was supposed to have caught fever from his close atten- 
tion on his brother during his illness and convalescence. What was 
most remarkable in the case, was, that his pulse began to flag and inter- 
mit, and he likewise suddenly and unexpectedly got the same symptoms 
of depression of the vital powers on the very same day and hour as his 
brother. His symptoms also continued for the same length of time, and 
yielded, or spontaneously ceased, under the same plan of treatment. In 
some families you will find a very curious coincidence between the play 
of the various functions in disease as well as in health, and you should 
neglect no opportunity of making yourself acquainted with the family 
peculiarities and idiosyncrasies of your patients, as knowledge of this 
description is of the greatest value and importance in the treatment of 
disease. 



LECTURE X. 

On Epidemics — On the use of Emetics in the commencement of Fever — Not so well adapted 
to a later period — Domestic remedies for feverish colds — These colds prove to be fevers, and 
time is lost — Protest against the abuse of purgative medicine in fever — The idea of curing 
fever by purging is absurd — Treatment where the bowels have become almost paralyzed 
after the cure of preceding diarrhoea — Venesection as a means of checking fever — Beneficial 
even within the first twelve hours after seizure by typhus — -Various cautions respecting 
leeching and cupping-glasses — Mode of applying leeches when pneumonia or hepatitis 
supervenes on fever. 

Having spoken at some length respecting epidemics, one only fact occurs 
to me in addition to those already detailed, viz. : It by no means follows 
when fever has a decidedly malignant type, that other acute diseases 
which prevail at the same time should exhibit a similar tendency ; thus 
measles and scarlatina are often epidemic simultaneously with fever, and 
yet each of the three may present a different type. This very year (1842) 
we witnessed a very widely disseminated epidemic of scarlatina, whose 
character was most malignant and fatal, and yet fever during that period 
was unusually mild in its form, while measles were rife and of a purely 
inflammatory character. Here then was a year during which fever, with- 
out becoming inflammatory, ceased to be typhus, scarlatina assumed a 
typhoid character, and measles prevailed, but of a pure inflammatory 
type! This statement, for the accuracy of which I can vouch, teaches 
how difficult it is to explain the causes which give to epidemics their 
peculiar complexion : indeed for the last five years scarlatina has been 
extremely malignant, and during the same period measles very benign ; 
so that we must not too hastily adopt the hypothesis that some general 
cause exists capable of simultaneously modifying diseases of different spe- 
cies — an hypothesis which has found many advocates, among the rest Dr. 
Watson, who says, " Sydenham found that measles of an unusually bad 
kind prevailed in London in the years 1670 and 1674 ; the very same 
years in which small-pox was also remarkably malignant and fatal. This 
illustrates what I have stated before, viz., that the typhoid tendencies of 
these and other febrile disorders depend less upon any peculiar virulence 
in their exciting causes, than upon some change previously effected in the 
human body by the silent and gradual influence of certain predisposing 
causes."* 

* Medical Gazette, September 9th, 1842, page 899. 



FEVER. 103 

I have already observed, that it is not my intention to give a systematic 
account of the practice to be adopted in the treatment of typhus. I have 
designedly passed over many important points, being unwilling to trouble 
you with any observations on practical matters in which my opinions 
coincide with the latest and best authorities. I shall therefore touch very 
briefly on the subject of emetics in fever, as the rules by which the admi- 
nistration of these remedies is regulated have been laid down with pre- 
cision by many modern writers. I am not in the habit of using emetics 
in fever, except when called in at the very commencement of the disease. 
Here emetics are of great value, and will often succeed in stopping the 
fever. There is no way in which you would be more likely to cut short 
an attack of fever than by the administration of an emetic, if you chance 
to see the patient when the fever is just beginning. I speak here with- 
out any subterfuge, and without grounding my opinions on the results of 
doubtful or merely suspicious cases. I speak not of cases of bad feverish 
cold, in which the symptoms, at the commencement, bear a very strong 
analogy to those which usher in typhus ; I speak of cases where the pa- 
tient gets rigors, followed by the usual symptoms of feverish excitement, 
after exposure to contagion, and is seen on the evening of seizure. If I 
were called to visit a patient who had been attacked with shivering, head- 
ache, quickness of pulse, increased temperature of skin, and lassitude, 
during the prevalence of an epidemic, or after exposure to contagion, and 
happened to see him a few hours after the attack, I should certainly bleed 
him, and administer an emetic : and I think he would have a very good 
chance of escaping the disease. I think the exhibition of emetics an ex- 
cellent practice in the commencement of fever, but I must observe that 
the period for their exhibition is very brief. After the lapse of twenty- 
four or thirty-six hours from the occurrence of the rigor, they will not 
succeed in cutting short the fever. A few hours make a vast difference 
in the chances, and after the lapse of twenty-four hours, there is, generally 
speaking, very little hope of extinguishing the disease. At the termina- 
tion of that period, it has in most cases seized hold of the constitution too 
firmly to be shaken off by an emetic, even though aided by bleeding, but 
for the first few hours after seizure, the plan I have mentioned affords you 
a reasonable hope of being able to put a stop to the mischief at once. 
Army surgeons, and practitioners who have opportunities of treating inci- 
pient disease, are well aware of the truth of these observations. I have 
myself witnessed many cases in private practice, of medical men and stu- 
dents, who had been attacked with symptoms of fever after exposure to 
contagion, and who escaped by taking an emetic and being bled in pro- 
per time.* 

* The annexed observations on the use of emetics at the commencement of fever, appear 
very judicious : — 

II When the opportunity offers of administering remedies in the first days of fever, an emetic 
may often be given with advantage, especially where the type of the fever is mild. An emetic 
clears the stomach of offending matters or sordes, which may be either undigested aliment, bile, 
thickened and vitiated mucus, or its own thin acid or acrid secretions. Besides which, an 
emetic has the additional advantage of determining the blood to the surface, and in this way 
relieving the oppressed state of internal organs. A powerful emetic may sometimes give the 
system a shock, sufficient to alter the course of the symptoms, and even to cut the fever short. 
This practice, however, is not without its dangers. In some cases it determines morbid action 
to the stomach, and renders that organ irritable during the whole course of the fever. At 
other times an emetic brings on local inflammation in some important viscus, on the same 
principle that it forces out sweat. As a general rule, we are not justified in giving an emetic, 



104 CLINICAL MEDICINE. 

Except at the commencement, I am not an advocate for the use of 
emetics in fever. They fail in checking the disease, and they are apt' to 
be followed by considerable debility of the stomach and general system — 
states which it would be better to avoid, where the patient has to run 
through the course of a long and exhausting disease. If called to a case 
of fever in which you cannot give an emetic, there are two or three other 
remedial agents you may employ to moderate the feverish excitement, 
and render the disease milder and more manageable during its progress. 
One of these is James's powder, with which you may combine blue pill 
or hydrargyrum cum creta, if necessary, giving two or three grains of 
each every third or fourth hour, according to circumstances. • Another 
remedy, w T hich many are in the habit of using, particularly where the 
fever is accompanied with symptoms of inflammatory excitement, is a weak 
solution of tartar emetic. Two grains of tartar emetic may be dissolved 
in a pint of barley-water, and of this mixture a tablespoonful may be. 
taken every second hour. These are good and useful remedies in the 
first stages of fever ; they moderate the feverish excitement, act gently 
on the bowels, and produce more or less diaphoresis. 

It most commonly happens that the physician is not called to see a case 
of fever until forty-eight hours, or perhaps three or four days, have elapsed, 
from the period of seizure. In this climate, feverish colds are extremely 
frequent ; and as their symptoms bear considerable resemblance to those 
of incipient fever, and very few are capable of making a distinction be- 
tween them for some time, a person attacked with fever usually regards 
it, at the first onset, as the result of cold, and expects to be able to alle- 
viate or remove it in a few days by bathing his feet and taking a warm 
drink at night, with, perhaps, some opening medicine on the following 
morning. The usual period, however, at which the feverish cold had 
been accustomed to decline, passes over without the expected amendment, 
the patient feels himself weaker and worse, the conviction is brought 
home to him that his disease is something more than an ordinary cold, 
and he sends for a physician about the third or fourth day. Now at this 
period, I believe, you must be content to let the fever run its course, for 
it has taken root too deep to be expelled by a coup demain, and yet many 
persons seem to think they can still succeed by what they term bold and 

unless we have reason to think that the stomach is foul, that is, loaded with acrid matters, 
whether formed within the body, or received into it from without." — Grkgoht's Practice of 
Medicine, page 112. Fifth Edition. 

In the following extract from Dr. Copeland's Dictionary, the experience of that eminent 
physician is laid before the reader : — " The arrest of fever may be also successfully attempted 
during the stage of invasion, or up to the commencement of vascular reaction or excitement ; 
but when once this period has supervened, the fever will run a regular course, although it will 
often be much shortened by treatment. Fevers, I believe, caused by infection, are very rarely 
arrested after reaction is established. The means just advised for the formative stage may 
likewise be tried in that of invasion; but much discrimination is requisite in the choice of 
means. Camphor, ammonia, and warm diaphoretics and diluents, sometimes with opium, 
when the head is not affected ; the warm bath, the vapour or heated air bath, and frictions, 
subsequently, are the most generally appropriate. In robust persons, and where terrestrial 
emanations have been the chief cause, a warm emetic and active stomachic purgatives may 
also be exhibited ; but they should more rarely be ventured upon in other circumstances, for 
the reasons just assigned. When there is tenderness at the epigastrium, with other signs of 
gastric irritation and depression of nervous power, instead of an emetic or cathartic, a large 
sinapism, or a warm turpentine epithem, should be placed upon this region, and over a great 
part of the abdomen ; or, in other cases, upon the inside of the thighs ; but neither of these 
ought to be resorted to if reaction have supervened, nor continued after it has come on." — 
Copeland's Medical Dictionary, page 921. 



FEVER. 105 

decided treatment. The mode which they generally adopt is, 6rst, to 
administer an emetic, and then to have recourse to copious and continued 
purgation. This leads me to say a few words on the use of purgatives in 
fever. 

The abuse of purgatives, particularly in the first stage of fever, con- 
tinues, I am sorry to state, even to the present day, a blot on the charac- 
ter of practical medicine. Large doses of calomel, and vegetable purga- 
tives, in the form of pill or bolus, followed by draughts composed of 
infusion of senna, Epsom salt, and electuary of scammony, form the chief 
part of the treatment in fever with too many practitioners. I know well 
that this is a mode of proceeding too commonly employed, and I have 
frequently heard those who adopt it, when questioned as to the remedies 
they have used, declare, with much self-satisfaction, that the patient's 
bowels have been well cleared out. This, I believe, is a very common 
mode of treating fever in the incipient stage; and though there can be no 
objection to the administration of a purgative, as a cautionary measure, 
particularly where an accumulation of fecal matter in the bowels is sus- 
pected, I must confess that my experience does not authorise me to say, 
that fever can be either checked or mitigated by continued purgation. If 
active purgation does not check fever in the commencement, what bene- 
fit, then, can be expected from it ? People will tell you that full purging 
must act beneficially in two ways ; by unloading the bowels, and by 
evacuating the general system. With regard to evacuating the bowels, I 
think it can be done well and sufficiently by the use of mild aperients. 
It is seldom necessary to give active purgatives, and we never have occa- 
sion to continue their employment from day to day. The bowels, I repeat, 
can be sufficiently unloaded by the exhibition of mild aperients and ene- 
mata, and even these will seldom be required more than once or twice in 
the commencement, and occasionally during the course of the disease. 
The second question (in reference to the use of purgatives as general eva- 
cuants) is, whether it is prudent or safe to act antiphlogistically on the 
system through the medium of the intestinal canal, during the first stage 
of fever ? My opinion is, that it is not. I grant that the administra- 
tion of active purgatives is followed by a copious evacuation of the 
fluid secretions of the intestinal canal, and that in this way you deplete 
the system to a very considerable extent. Admitting all this, and, more- 
over, that depletion is required, still I am of opinion that this is not the 
best way of effecting it, and shall always give a preference to the action 
of other remedies. I prefer the action of James's powder, or tartar emetic, 
or nitrate of potash, or leeches, or, in fact, any remedy which will act 
with less risk of subsequent mischief. I have observed that the abuse 
of active purgatives in the commencement of fever— nay, even the exhi- 
bition of cathartics two or three times, in the beginning of fever, in per- 
sons with irritable bowels, is very apt to induce excitement of the gastro- 
intestinal mucous surface, giving rise to early and profuse diarrhoea, 
tympanitis of a bad and unmanageable character, and not unfrequently to 
disease of the mucous coat of the digestive canal. Great tenderness of 
the belly, meteorism, and exhausting diarrhoea, are the general conse- 
quences of early and continued purgation. In private practice I can 
generally tell, by examining the patient's belly, whether he has been 
actively purged in the commencement of the disease or not. I invite you 
to study the cases that come before you in hospital, with reference to this 



106 CLINICAL MEDICINE. 

point ; I think you will find in most instances, that the patients who have 
escaped active purgation before admission, will get through the disease 
with little or no tympanitis. The physician who merely employs mild 
aperients and enemata — who does not use active purgatives from day to 
day, as is too often done — will not have his plans of treatment embar- 
rassed by the occurrence of dangerous tympanitis, or obstinate and debili- 
tating diarrhoea ; nor will he have the melancholy prospect before him of 
having an inflammatory affection of the gastro-intestinal mucous membrane 
to treat, at a period when neither the condition nor the constitution of the 
patient will bear any thing like antiphlogistic measures. As to purging 
in general, the idea of curing fever by it is quite absurd. In fever, all 
the secretions are affected, and it w T ould be idle to think of altering and 
improving all by acting on the bowels. Take the skin, for example. 
Consider what a departure there is from the normal state ; observe the 
quantities of moisture which exude from it without any apparent cause, or 
its equally inexplicable dryness. Its odour, its feel, its nervous and vas- 
cular conditions, are all more or less altered. Take the lungs, in the 
next place. There is generally some change in the smell of the patient's 
breath ; there is some change also in the quantity of the pulmonary exha- 
lation ; there is an alteration in the rate and mode of respiration ; and 
I have ascertained, by experiment, that a person in fever does not con- 
sume as much oxygen, or give out as much carbon, as he would in a 
state of health. Observe the functions of the brain, or those of the liver 
or kidneys, and see how much they have departed from the normal state. 
Every secretion, every function, is more or less deranged, and will remain 
so as long as the fever lasts. You have no right to think that you will 
be able to restore the healthy state of the stomach and bowels any more 
than that of any other organ. The secretions of the lungs, liver, pan- 
creas, kidneys, stomach, and skin, are all deranged, or more or less sup- 
pressed, and will not be restored to a healthy state until a crisis come 
on, or the disease begins to decline. As long as the belly is soft and 
fallen, and where the bowels have been sufficiently opened in the com- 
mencement of the disease, I do not feel the least anxiety if the patient 
remains without having a stool for two or three days. I have, on some 
occasions in private practice, been induced to consent to the exhibition 
of a purgative where I did not think it required ; and have seldom done 
so without regretting it afterwards. The patient has been going on well, 
the belly soft and fallen, no tenderness present, and no distinct evidence 
of fecal accumulation. All this I have pointed out to the practitioners in 
attendance with me, but to no purpose. They would generally observe, 
in reply, " Oh ! this may be all true ; but you see the patient has had no 
stool for the last thirty-six hours, and it would be quite wrong to let him 
go on in this way any longer." Indeed, you will frequently meet with 
cases in which you should exercise much caution in the administration 
even of enemata. An illustration of this remark occurred to Surgeon 
O'Ferrall and me lately in practice. In a case of fever in which the pa- 
tient's friends were importunate as to the necessity of opening the bowels, 
the ordinary purgative injection was prescribed. It proved too active, 
and produced much irritation of the bowels, giving rise to an increased 
secretion of gas into the intestines, and a considerable degree of tempo- 
rary tympanitis. 

You will be guided, therefore, in the administration of purgatives, not 



FEVER. 107 

by the rule of those who are dissatisfied with less than two or three motions 
in the day, but by the circumstances and exigencies of the case; and you 
will be cautious in giving purgatives, except where you have good rea- 
sons to conclude that there is an accumulation of feces. In this way you 
will avoid tympanitis, diarrhoea, and inflammatory affections of the bowels ; 
symptoms which always give great annoyance to a practitioner, and tend 
greatly to embarrass his practice in the treatment of all fevers of a typhoid 
character. 

So far concerning the administration of purgatives as a cure for fever, 
or as a means of diminishing its violence. You perceive that I think their 
employment more than questionable, and in this particular am consequently 
at issue with Hamilton, and a great number of writers. There are, how- 
ever, circumstances which may arise during the course of typhus, and may 
require a free use of purgative medicines; we are then forced to have re- 
course to purgatives, not in the hope of curing the fever itself, but for the 
purpose of removing or alleviating certain superadded symptoms. It may 
be well to mention some of the chief of these symptoms. One of the most 
common is determination of blood to the head, producing delirium, head- 
ache, &c. &c. In many examples of this nature, occurring at an early 
period of typhus, purgatives of a very active nature are amongst our most 
efficacious remedies. Nay, even in the advanced stages of fever, delirium 
and determination to the head are seldom relieved by tartar emetic, unless 
it produces very copious, yellow, watery stools. Many patients become 
uneasy and restless at night, in the latter periods of fever, in consequence 
of insufficient evacuations from the bowels; whenever, therefore, restless- 
ness or sleeplessness supervene unexpectedly, and that the bowels are con- 
fined, the occurrence of these symptoms call for aperients, even though the 
belly be not very full and tumid. Preternatural fulness of the belly, and 
tympanitis, often demand purgatives at every period of the disease. In 
some cases, when a troublesome diarrhoea has yielded to astringents, a very 
obstinate and long-continued state of constipation comes on, apparently 
connected with impaired muscular power of the intestinal tube. At first, 
this confinement of the bowels produces no uneasiness on the part of the 
medical attendant, inasmuch as it is unattended by any fulness or tension 
of the abdomen, and the patient may, in other respects, appear to be doing 
well. After some days, however, it is judged prudent to excite alvine 
evacuations, which is attempted cautiously, for the practitioner bears in 
mind the violence of the previous diarrhoea. He therefore chooses mild 
purgatives at first, and next day, finding them ineffectual, he ventures on 
the exhibition of more active medicines, and orders a frequent repetition 
of injections. Even these steps fail, and constipation continues for several 
days after the efforts to remove it have been commenced. This is a junc- 
ture full of difficulty. In such cases, much caution must be used in em- 
ploying active cathartics, and great care should be taken to remove any 
hardened feces which may be present in the rectum or sigmoid flexure of 
the colon. This must be done partly by the finger, or by means of an ap- 
propriate scoop, as, for instance, a marrow-spoon, and by injections of soap 
and water. When no such mechanical obstructions exist, to account for 
the failure of the cathartics, we must proceed cautiously, and not rashly 
accumulate medicines of this description in the stomach and bowels of the 
patient. Very active purgatives, though they fail to stimulate the para- 
lyzed bowels so as to evacuate their contents, may yet irritate the intesti- 



103 CLINICAL MEDICINE. 

nal mucous membrane, and cause destructive inflammation. For this rea- 
son, where moderate doses of colocynth, gamboge, jalap, scammony, rhu- 
barb, &c, have failed, they must not be repeated; neither, except in des- 
perate cases, ought we to administer croton oil internally. The neutral 
salts, senna, magnesia, and, above all, castor oil, given combined with 
spirits of turpentine, or uncombined and very frequently repeated, must 
be our chief internal medicines. In some cases, the compound decoction 
of aloes, with small doses of sulphate of magnesia, will succeed in excit- 
ing the paralyzed bowels to action, where other and more powerful purga- 
tives have failed. Injections should be perseveringly repeated, and varied 
both in quality and quantity; and they should be always thrown as far 
as possible into the bowel, by means of a flexible tube and Read's syringe. 
When they are retained, and excite swelling of the belly, as too frequently 
happens in these cases, we must desist from their use. 

This obstinate state of constipation may be supposed to depend on a 
degree of paralysis of the bowels; for usually in such cases an evident 
paralysis affects the bladder, causing retention, or its sphincters, giving rise 
to an involuntary dribbling of urine. 

On the subject of bleeding in fever, I have but very few remarks to offer. 
In the first place, with respect to the power which venesection possesses 
of checking fever, it may be observed, that there can be no.doubt that it 
has frequently been found capable of effecting this purpose, particularly 
where it has been properly employed, and in conjunction with other means. 
I speak here with reference to cases in which bleeding has been used under 
favourable circumstances, and very soon after seizure — as in students, 
medical practitioners, hospital attendants, soldiers, and seamen. In such 
persons, and others where circumstances have been equally favourable, 
there is no doubt that venesection has frequently succeeded in cutting short 
fever; and if called to a case of typhus within the first ten or twelve hours 
after seizure, I should have no hesitation in having recourse at once to 
venesection, followed by an emetic; and my own experience convinces 
me that I should afford my patient a very good chance of escaping the dis- 
ease. I have on several occasions succeeded in arresting the progress of 
fever by these means; and the records of naval and military practice fur- 
nish many proofs in corroboration of my statements. I have also the au- 
thority of Dr. Cheyne (whose experience on every point connected with 
fever was immense) in favour of the efficacy of bleeding in commencing 
fever, as a mode of treatment which has frequently proved successful in 
his hands. But it is only in the very commencement, and during the stage 
of rigor, that you can hope to derive any advantage from venesection in 
cutting short an attack of fever. I do not mean to say that you have in 
typhus, as intermittent, distinct rigors, lasting each for half an hour, or 
even longer ; by the stage of ri^or in typhus, I mean to designate the 
period of formation, during which the patient complains of recurrent 
chills, although his skin feels hot to the touch when examined by another 
person. This stage lasts generally from twelve to twenty-four, and in a 
few cases to thirty-six hours ; and it is only during this stage that you 
have a chance of extinguishing the fever at once, by the abstraction of 
blood from the system. 

You may also have recourse to venesection within the first day or two, 
for the purpose, not of arresting fever at once, but of lowering inordinate 
vascular action, in persons of a robust habit, and where the fever sets in 



FEVER. 109 

with violent headache, great heat of skin, and a firm bounding pulse. 
We do not, however, at present meet with many such cases, nor are we 
often called in at a period when venesection might be advantageously 
practised. The physician seldom sees a case of fever until the third or 
fourth day, and then it is too late to think of general depletion by the 
lancet. This explains why venesection is so seldom employed in typhus 
in our hospitals. Moreover, in entering on the treatment of any case of 
fever at present, you should bear in mind the nature of the prevailing epi- 
demic, and be careful how you proceed with respect to bleeding; and if 
you take away blood, do not go so far as you would if treating a case of 
lever under different circumstances, and of a genuine inflammatory cha- 
racter. I know that many persons have asserted that you can bleed in all 
cases of fever, no matter what the state of debility may be ; because this, 
they say, is only apparent, and depends upon congestion and oppression 
of vascular action. I do not know how far this doctrine may be applica- 
ble to other epidemics, but in the present fever it certainly does not hold 
good ; and no man in his senses would think of adopting it as a guide for 
his practice. I have seen some of the most intense, dangerous, and pro- 
tracted cases of fever, commence without any appreciable increase of vas- 
cular action, with a soft slow pulse, a cool skin, no symptoms of conges- 
tion of any internal organ ; in fact, without any thing which would, even 
in the youngest and most robust habits, call for the use of the lancet. In- 
creased vascular action, and this you should always bear in mind, is not 
in itself a proof of an inflammatory diathesis in fever, but rather one of a 
set of symptoms produced by the same morbid cause. The heat of skin 
and rapidity of pulse are, just like the debility, products of the same mor- 
bid cause, and not the results df inflammation. You should also recollect 
that in fever, as well as in other diseases in which the nervous system is 
greatly deranged, the pulse is not unfrequently a very deceptive guide. 
In many cases of fever, where the patient happens to be of an irritable 
habit, the pulse exhibits a degree of thrill and apparent hardness, which 
might lead an inexperienced or unobservant practitioner into serious errors. 
I do not mean to say that an inexperienced linger will not be able to dis- 
tinguish a pulse of this kind from one of genuine hardness, but I know 
that many persons have been misled by it, and I warn you against the 
danger. 

Again, never use the lancet when there is any, even the slightest, ap- 
pearance of maculae, no matter how intense the headache, heat of skin, 
or signs of general vascular action, may be. I have seen some cases in 
which the lancet was used during the presence of macula?, and I have 
seen its employment followed by the most lamentable consequences. You 
should, therefore, never omit to examine the skin, for circumstances might 
occur which would authorise a moderate use of the lancet, provided there 
was no sign of maculae present. Formerly, persons were very much in 
the habit of employing arteriotomy when the headache and delirium were 
violent, regardless of the period or stage of fever ; and nothing was more 
common than to see a physician ordering the temporal artery to be opened 
on the eighth, ninth, or even tenth day. This was very much the prac- 
tice during the time when the doctrine of typhus being the result of in- 
flammation of the brain prevailed in this country and England, and a very 
unsuccessful practice it was. You perceive we seldom have recourse to 
arteriotomy here ; it may be occasionally necessary, and when it is, we 



110 CLINICAL MEDICINE. 

employ it ; but as a general practice it does not appear entitled to any 
merit, nor can we give it our recommendation. 

The examples which you have seen in hospital show you that local in- 
flammation arises, generally speaking, at a period when general bleeding 
is no longer admissible. I have spoken already of the mode in which 
leeches are to be applied to the head, with the view of relieving head- 
ache and cerebral congestion ; it is not necessary that I should say any 
thing respecting their application to the epigastrium, or abdomen, for the 
relief of gastro-intestinal symptoms in the beginning of fever, as there is 
very little chance of your doing any mischief, even by the free use of 
leeches, at this period ; it only remains for me to make a few remarks on 
the use of leeches and cupping-glasses, in the more advanced stages of 
the disease. Well ; your patient, suppose about the ninth or tenth day, 
gets pain in his side, cough, and increased frequency of respiration, and, 
on examination, you find sufficient evidence of the existence of pneumo- 
nia. Or he complains of abdominal symptoms, and you have strong rea- 
sons to think that hepatitis or enteritis is present. Here you will have 
recourse to leeches or cupping, according to the circumstances of the ease. 
An attack of pneumonia, coming on in fever, frequently acts as a stimulus 
to the economy ; the collapse of fever disappears more or less, and the 
pulse becomes more firm and resisting. This is a fortunate occurrence, 
for under such circumstances the patient is better able to bear depletion, 
and you may proceed at once to apply cupping-glasses or leeches to his 
chest, regulating the quantity of blood you abstract, not only with refer- 
ence to his present symptoms, but also to his future condition. But it 
sometimes happens that pneumonia occurs at a later period of the disease, 
and when you cannot use cupping-glasses, or even leeches, to any great 
extent. In such cases (and the same remark will apply to enteritis, or 
any other inflammation occurring in the advanced stage of fever), you 
should leech with great caution : begin with four or six at a time, and 
when they drop off, cover the leech-bites with a cupping-glass. In this 
way you will know pretty nearly the exact quantity of blood which the 
patient has lost, and you can arrest it with less difficulty afterwards. You 
can then have recourse to calomel and opium, or tartar emetic, according 
to circumstances. Leech as far as you can, and then have recourse to 
immediate blistering, and such other means as the exigencies of the case 
may demand. 

You may leech, then, freely, and without any particular caution, in the 
commencement of fever, whether it be for cerebral, or for thoracic, or 
abdominal symptoms ; but as the fever advances, you must exercise more 
discrimination and care, both as to the number of leeches you apply, and 
the time you allow them to bleed.* In applying leeches to the head, I 



* [Dr. Graves's remarks respecting the propriety of omitting venesection 
when the disease is at all advanced, are now almost universally admitted. 
There is no doubt of their entire correctness. Even at the earliest stages 
of the disease, venesection is not generally advisable. Cupping is a bet- 
ter mode of taking away blood locally than leeching, which indeed is 
scarcely practicable in most parts of the country. Cups may be used 
when there is much flush of the countenance and a tendency to active 
delirium. When the delirium becomes less active in its character, cup- 
ping should either be used very sparingly, or entirely avoided. — W. W. G.] 



FEVER. Ill 

would advise you not to put them on both temples, or behind both ears 
at once, as this is awkward, and prevents the patient from lying on either 
side. You may also, in cases or* cerebral irritation, apply them to the 
nostrils or septum marium ; in this way you will be able to get away a 
large quantity of blood by means of very few leeches, for one or two at a 
time will be sufficient. In leeching the chest and abdomen in particular, 
I advise you never to have recourse to fomentations with the view of 
getting more blood from the leech-bites. Fomentations are too often a 
source of fresh mischief in cases of this kind, leading to exposure of the 
patient to cold, and to the annoyance of having his linen and bedding 
kept wet for hours together. Always give directions to have cupping- 
glasses, or hot dry flannel cloths, applied as soon as the leeches drop off, 
and you will have less difficulty in arresting its flow afterwards, a point 
of some importance in cases where the loss of even a trifling quantity of 
blood is often of great moment, and likely to have a very powerful effect 
on the state of the patient. 



LECTURE Xf. 

Fever — Application of col. I to the head ; particular apparatus for (his--Warm applications 
recommended — Use of mercury in fever — Effects of Intemperance — Illustrations afforded by 
particular cases — Necessity of active attention to cerebral symptoms — Occasional absence of 
morbid appearance after death — Contraction and dilatation of the pupils — Coup de soleil — 
Flatulent distension accompanied by delirium, coma, &c, treated by spirit of turpentine with 
success. 

I have already laid before you my views as to the use of general and 
local bleeding in fever, and pointed out the circumstances under which 
they might be employed. In treating of general bleeding, I stated that 
we used it at the commencement of fever, with a view of checking the 
disease altogether, or of rendering it milder and less dangerous, by 
moderating excessive inflammatory action, and controlling cerebral excite- 
ment. I have also spoken of the use of leeches and blisters, and it only 
remains for me to say a few words respecting the application of cold to 
the head as a means of moderating or removing symptoms of cerebral 
excitement. In Dr. Southwood Smith's Treatise on Fever, you will find 
many cases and arguments to show that where headache and delirium are 
present, and where the lancet is inadmissible, if you place the patient in a 
warm bath, and direct a forcible small stream of very cold water on his 
head, he soon becomes more calm, experiences great relief of his head- 
ache, and is frequently brought back to his bed quite free from cerebral 
symptoms. The burning heat of the skin is quickly replaced by a sensa- 
tion of coolness, or even cold, the flushing of the face disappears, the 
delirium vanishes, and a favourable crisis is often produced. Indeed the 
effects of this remedy are extremely remarkable, and I have no doubt 
that many of the cases in which I have employed tartar emetic with such 
signal advantage would derive equal benefit from this mode of treatment. 
The cold affusion, as recommended by Dr. Smith, and practised at the 
Charite Krankenhaus, at Berlin, is most certainly an excellent and ener- 
getic remedy, and I regret that we have not apparatus in this hospital for 



112 CLINICAL MEDICINE. 

applying it ; but I fear its utility must be, at least for some time, limited 
to public institutions, and that it cannot be employed to any extent in 
private practice. There is a good deal of prejudice against applications 
of the kind in this country. At the time, that cold affusions were used in 
the treatment of scarlatina, much mischief was done by their indiscrimi- 
nate employment, and this added to the general feeling of dislike towards 
them. At all events, cold affusion is a remedy which requires an appa- 
ratus seldom at the command of the physician in private families, and, 
indeed, I think that in most cases we may do very well without it. 

You are all aware, that in cases of determination to the head, the com- 
mon practice is to shave the scalp, and apply cold lotions. In my pub- 
lished lectures, I have endeavoured to point out the imperfect, and even 
hurtful, mode in which this remedy is ordinarily applied, and to show that 
it is calculated rather to increase than diminish the heat of the integuments. 
Cold lotions act as a powerful refrigerant, if constantly repeated, so as to 
keep the part below the standard temperature of the body. But this is 
seldom or never done. The nurse applies the lotion, and then, perhaps, 
drops asleep, or occupies herself with some other business^ until at last 
she is attracted by the vapour arising from the patient's head, and then 
she renews the application. I need not say, that in this way all the good 
effects of cold, as a refrigerant, are entirely lost, and that a degree of re- 
action is produced which must altogether mar and nullify its application. 
I have, therefore, given up, except in very few cases, the practice of ap- 
plying cold lotions, and give a preference to the use of warm fomentations 
of equal parts of vinegar and hot water, applied to the temples and shaven 
scalp, and frequently repeated. I am quite sure we employ warm appli- 
cations for the relief of headache and cerebral symptoms much less fre- 
quently than we ought. You are aware that surgeons are in the habit of 
treating some local inflammations with warm, and others with cold appli- 
cations, and that the rules laid down for distinguishing the cases in which 
cold, and those in which warm, fomentations should be used, are deficient 
in precision, and that most commonly the practitioner has to refer to his 
own individual experience for the guidance and determinationof his choice. 
So it is, also, with respect to the use of fomentations, to relieve the pain 
and congestion of internal parts, among which I include determination to 
the head in fever, accompanied by intense headache, restlessness, and de- 
lirium. In some cases of this description, cold applications will give ease; 
in others, most relief is obtained by fomenting the head w T ith water as hot 
as it can be borne. 

The idea of employing hot fomentations in cases of this description was 
first communicated to me in 1833, by the late Mr. Swift, who became ac- 
cidentally aware of their value while washing his face one day in very 
warm water, at a moment when labouring under severe headache. The 
sudden relief obtained by the application of hot water, induced him to try 
it extensively in the headache of influenza, and with the most satisfactory 
results. You are aware, that in the influenza which appeared in this coun- 
try in 1833, one of the most remarkable symptoms was intense headache. 
This was accompanied with great debility, and was not amenable to the 
ordinary modes of depletion. Now, Mr. Swift found that by applying 
water, as hot as it could be borne, to the forehead, temples, and back of 
the head, great and almost instantaneous relief was obtained, and that in 
this way he was able to keep a most unpleasant symptom in check, while 



FEVER. H3 

he was taking measures to remove the disease. I afterwards heard from 
my friend, Dr. Oppenheim, of Hamburg, that he had also discovered that 
this was the best means of affording relief under the same circumstances. 
This led me to think of applying hot fomentations to the head in other dis- 
eases, and although I cannot give you any particular rules for determining 
the cases in which you should employ them, I can say that you will gene- 
rally find warm vinegar and water the best and most efficacious applica- 
tion in the ordinary headache of fever. 

I shall close this lecture with a few observations on the use of mercury 
in fever, and this will include all I have to say at present on the remedies 
most generally employed in the treatment of typhus. Are we to have re- 
course to mercury, or not, in typhus? I do not allude here to its use as 
an aperient, but when called to treat a case of fever, are you to proceed 
at once to bring the patient's system under the influence of mercury? Are 
you, in addition to the other measures usually adopted in the treatment of 
fever, to go on with the administration of mercury until you affect the 
mouth, and bring on salivation? This was the practice in my earlier days, 
and great confidence was placed in it by the majority of practitioners. It 
has been also very extensively recommended by army and navy surgeons, 
in the treatment of tropical fevers, but I must confess that I am not at all 
inclined to adopt this practice, and that I have seen abundant reasons why 
I should neither employ nor recommend it. In the first place, we have 
observed in our wards that patients with other diseases have frequently 
caught fever from exposure to infection, at a time when they were fully 
under the influence of mercury. In the next place, we have observed that 
persons who were thus attacked with fever while in a state of salivation 
did not escape better than others, and that in them the disease ran its full 
course, aggravated rather than diminished in its danger by the pre-exist- 
ing mercurialization. These facts I have frequently seen verified in hos- 
pital and private practice. You perceive, then, that mercurialization nei- 
ther protects a man from the contagion of typhus, nor does it produce a 
favourable modification in its type or progress. Again, I have repeatedly 
witnessed the daily and continued exhibition of mercury in fever, and I 
cannot recollect a single case in which it appeared to check the disease, 
moderate its symptoms, or bring about a favourable crisis. I am aware, 
that in entering my protest against this practice, I dissent from a very con- 
siderable body of my brethren, who, from the beginning to the end of fever, 
never cease in their attempts to bring the patient's system under the influ- 
ence of mercury. 1 am convinced that, in the cases in which recovery is 
stated to have followed this practice, the post hoc has been mistaken for 
the propter hoc. Besides, fever is one of those affections in which you will 
find it extremely difficult, and often impossible, to bring the system fully 
under the influence of mercury. There are certain states of the system 
which prevent altogether the full operation of mercury, and bad typhus 
is one of these states. Where fever has laid deep hold of the constitution, 
you cannot affect it with mercury. When a patient recovers who has been 
mercurialised during the course of fever, he does not recover because his 
system came under the influence of mercury, but he comes under the in- 
fluence of mercury because he recovers from the fever. Add to this, that 
mercury is a remedy which requires a peculiar regimen, and that it is very 
apt to engross the practitioner's attention, and prevent him from the exhi- 
bition of remedies which are more directly indicated, and in reality more 
9 



114 CLINICAL MEDICINE. 

useful. These considerations, and others, have convinced me that the 
exhibition of mercury in fever, with the view of touching the gums, is inju- 
dicious and unnecessary. There are, however, cases in which you will 
be compelled to have recourse to mercury, whatever the stage or type of 
the fever may be. Whenever inflammation of some internal organ — as, 
for instance, of the lungs — arises during the progress of fever, you must 
employ mercury at once; and cases of pneumonia, which would have 
proved fatal, have, on numberless occasions, been treated successfully by 
mercurialization. But under ordinary circumstances, and were' there no 
indication similar to that which I have just pointed out, I do not see any 
advantage to be derived from the use of mercury. I am not, therefore, 
in the habit of employing mercury in fever. Sometimes I use calomel as 
an aperient, and I frequently prescribe small doses of hydrargyrum cum 
creta, with the view of gently stimulating the liver, and preventing the 
tendency to congestion of the intestinal canal; but farther than this I am 
not in the habit of going; and I never, except in cases of pneumonia, or 
inflammation of some internal organ, attempt to bring the patient's system 
under the influence of mercury during the course of typhus. 

Permit me next to direct your attention to the case of the patient Murphy, 
who died last week. This case excited a good deal of our attention at 
the time, and I wish to make some further observations on it while it 
remains fresh in your minds. 

It was one of those mixed cases of typhus, in which, as the fever 
advances, we observe the usual phenomena of determination to the head, 
accompanied by a train of symptoms which bear a close analogy to those 
of delirium tremens. Among the pauper population which we have to 
treat, you will frequently meet with cases of this description. We wit- 
nessed many examples of it here, but not so many as are to be seen in 
other hospitals. It is a melancholy but well-known fact, that a great 
proportion of the diseases which come under our notice, in the acute as 
well as in the chronic form, are more or less complicated with intem- 
perance.* This you should never forget. In persons of the lower class, 
who are addicted to the daily use of spirituous liquors, you will find 
disease assuming a thousand unfavourable shapes and complications. You 
will find their fevers intermixed with various symptoms of an anomalous 
or dangerous character, and their chronic affections embarrassed by organic 
and visceral disease. You will be repeatedly struck with the strange and 
protean character which disease assumes under the influence of an habitual 
intemperance ; and you will often, in the course of your practice, have to 
endure the annoyance and disappointment of seeing your patient carried 
off by some new and unexpected malady, after you have succeeded, by 
infinite toil, ingenuity, and patience, in removing every trace of his primary 
affection. 

The case of Murphy was one of those which have been neglected in 
the beginning, where the vantage ground has been lost, and the chances 
of success are diminished almost to nothing. You have observed that all 
the fatal cases of fever which we have had in hospital were cases admitted 
at an advanced period of fever, and in which the head had been neglected. 
You have also observed how exceedingly difficult it must be to treat cases 

* Since this lecture was delivered, a great change for the better has been effected by the 
efforts of the Rev. Mr. Matthew — the poorer and working classes of Ireland are now distin- 
guished for temperance. 



FEVER. 115 

of this description. The patient is admitted at an advanced stage of 
fever, and at a period when he can give no account of his present or past 
symptoms, or the mode of treatment to which he has been submitted. 
He comes in with delirium, or coma, and subsultus tendinura ; his symp- 
toms are certainly cerebral, and he exhibits, perhaps, a blistered scalp ; 
but we can have no means of ascertaining whether he has headache, heat of 
scalp, throbbing of the carotid and temporal arteries, or vertigo — we can- 
not, in fact, decide with precision as to the exact state of the brain, and our 
practice must be embarrassed by more or less doubt and obscurity. I have 
already impressed upon your attention the urgent necessity of watching 
the head in fever, and I think I cannot too often reiterate the advice which 
I have given you, to endeavour to check cerebral symptoms before they 
amount to any degree of absolute danger. The fate of those who have 
died here will convince you that when cerebral disease has once arrived 
at its acme, the most energetic measures will often fail in arresting it. It 
is a matter of vital importance, then, to prevent this lamentable state of 
things, and, without waiting until the symptoms of cerebral disease 
manifest themselves, to anticipate in its very origin, and thus be enabled 
to control with certainty symptoms which assume such a fearful aspect in 
cases where cerebral disease has been allowed to go on unregarded. This 
is the practical lesson which I wish you to draw from the four fatal cases 
which have occurred in this hospital within the last month. 

There are some points in the case of Murphy to which I wish to recall 
your attention, as I am anxious that you should make them the subject of 
reflection. For some days before his death, he had been delirious and 
unmanageable, with total loss of sleep and a contracted state of the pupil. 
The antiphlogistic and derivative treatment had been employed without 
effect ; and seeing that his symptoms were advancing, and his sleepless- 
ness undiminished, I ventured to give him an injection, consisting of two 
grains of tartar emetic with ten drops of laudanum. I am cautious in the 
administration of opium in the advanced stage of fever, where there is 
evidence of determination to the head ; and it was on this account that I 
ordered it to be combined with tartar emetic, giving also directions that 
the effect of each dose should be carefully watched. He got three ene- 
mata during the course of the night — that is, thirty drops of laudanum 
altogether. He dozed after the last injection, and appeared more tran- 
quil ; but at our morning visit we found him in a state of coma, with 
rapid sinking of the powers of life, and death took place in the course of 
a few hours afterwards. I must confess the issue of the case gave me 
some degree of uneasiness at the time, as I thought it might have been 
precipitated by the administration of the opium. I could not say but that 
even this small quantity of opium might have greatly aggravated the cere- 
bral symptoms, and accelerated the fatal event. Dissection, however, 
revealed the true cause of death. On opening the brain, we found ex- 
tensive arachnoid inflammation, some effusion on the surface of the brain, 
and an intensely congested state of its vessels. The patient, altogether 
dissipated in his habits, and greatly reduced by fever, had been a young 
man of rather robust constitution previous to his illness ; he had been 
neglected in the beginning of his fever, which, from the phenomena ob- 
served after death, must have been characterised by early and decided 
determination to the brain, producing delirium, watchfulness, coma, and 
a contracted state of the pupil, which all our antiphlogistic measures were 



116 CLINICAL MEDICINE. 

inadequate to remove or control. We did every thing in our power : we 
leeched, blistered, and gave tartar emetic, but without effect ; the case 
had not come under our care until symptoms of unmanageable cerebral 
disease had been established. This state of delirium, followed by con- 
traction of the pupil and coma, and terminating in death, occurs in two 
classes of cases: first, in hospital patients of the lower class, who have 
been neglected in the commencement of fever ; and secondly, in persons 
in the better classes of life, in whom the mind is frequently subjected to 
over-exertion, and who, when attacked by fever, exhibit a strong ten- 
dency to the early development of cerebral symptoms of a bad and un- 
manageable character. One of the worst symptoms observed in such 
cases is extreme contraction of the pupil. I have seen the pupil in some 
cases contracted to the size of a pin-hole ; and I think I can state, that 
out of all the cases of this description which I have witnessed there were 
but two recoveries. I have seen persons who had exceedingly bad and 
alarming symptoms of cerebral derangement recover, although accompa- 
nied by great dilatation of the pupil ; but I think I have seen but two 
cases recover in which the pupil was contracted to the small size observed 
in Murphy. 

With these facts fresh in your minds, allow me to direct your attention 
to the case of another man, who died lately in the fever ward with cere- 
bral symptoms of an intense character. Now, in this man the very same 
train of phenomena were present which we observed in Murphy's case. 
He had, you recollect, typhus of a low character, accompanied by deli- 
rium, subsultus, and the ordinary symptoms of determination to the head. 
I defy any man who compared these two cases together to point out any 
remarkable difference between them. The delirium, nervous excitement, 
and watchfulness, commenced the same w T ay in both, and ran through 
the same course ; both had contraction of the pupil, constant muttering 
and delirium, persistent watchfulness, and subsultus tendinum ; and in 
both the cerebral symptoms terminated in coma and death. I would 
defy the most accurate symptomatologist to point out any marked distinc- 
tion between them. Yet how different were the phenomena observed on 
dissection ! In the one there was extensive lesion of the membranes of 
the brain, effusion on its surface, and intense congestion of its vessels; in 
the other, there was no appreciable departure from the normal condition. 
These are very strange things, and well worthy of attentive consideration. 
But it is not in typhus alone that we meet with the occurrence of analo- 
gous symptoms — in cases which exhibit a \ery different state of the brain 
after death. We are encountered with the same puzzling contrarieties in 
many cases of scarlatina. Cases come under our notice in which the 
patients appear to die entirely from the violence of the cerebral symptoms, 
and yet, on examination, we find very dissimilar states of the brain. In 
some, there is palpable and fatal lesion — in others, there are some dubious 
marks of congestion, quite insufficient to account for the symptoms ; or 
the brain is found to be perfectly sound and normal. 

It would appear that in scarlatina and fever, the poison of the disease 
exercises a deleterious influence on the brain, independent of inflamma- 
tion, but capable of producing an analogous train of symptoms. Hence it 
is in many cases extremely difficult to distinguish the cerebral symptoms 
produced by the poisonous influence of fever on the brain, from those 
which depend on true inflammation. The one gives rise to delirium and 



FEVER. 117 

fatal coma as well as the other ; and in the advanced stage of fever, when 
the manifestations of nervous energy are feeble and imperfect, and when 
the circulating and respiratory organs act with diminished power, the dis- 
tinction between mere irritation and actual inflammation becomes a matter 
of great difficulty. 

In alluding, on a former occasion, to the occurrence of analogous symp- 
toms under opposite conditions of the brain, I noticed that headache, tin- 
nitus aurium, and giddiness, have been observed in cases where there 
was distinct evidence of determination to the head, as well as where there 
was every reason to believe that the supply of blood to the brain was 
greatly diminished. You will find a very curious illustration of this fact 
in the last number of Guy's Hospital Reports, which contains a very in- 
teresting paper from Sir Astley Cooper, on the effects produced by tying 
the carotid and vertebral arteries. Among other results, it appears that 
when the supply of arterial blood destined for the brain is diminished, 
the animal experimented on becomes stupid, is to a certain extent inca- 
pable of voluntary motion, and exhibits a very remarkable dilatation of 
the pupils. This is an extremely curious fact. You are all aware that 
dilatation of the pupils has been long regarded as one of the most charac- 
teristic signs of extravasation and increased pressure on the brain ; and 
yet it appears the very same condition of the pupil is observed when yoif 
cut off the supply of arterial blood to the brain. We are, I fear, as yet 
very much in the dark as to the derangement of function which occurs in 
the brain under opposite states of its vessels ; and I think we have equally 
imperfect and confused notions of the changes which take place in that 
organ as the result of fever. 

Dilatation of the pupils is usually regarded as a sign of increased pres- 
sure on the brain ; and when hydrocephalic symptoms are present, it is 
generally looked upon as pathognomonic of etfusion. Yet from the ex- 
periment just alluded to, we find that dilatation of the pupil is also the 
result of a state of things in which we cannot suppose the existence of 
any thing like increased pressure on the brain. When I speak of increased 
or diminished pressure on the brain, I am not prepared to maintain that 
such is actually the case, or that when a man becomes giddy and faints, 
after bleeding, the actual quantity of blood circulating in the brain is 
diminished, and consequently the amount of pressure ; but when a man 
gets headache, vertigo, or syncope, from loss of blood, it must depend 
upon causes different from those which are connected with congestion of 
the brain, or extravasation on its surface, or into its substance. What I 
wish to impress upon your minds is, that dilatation of the pupils may be 
connected with very opposite states of the cerebral circulation ; and that 
in fever it cannot of itself be regarded as a sign of paramount value in 
determining the existence of congestion or inflammation of the brain. 

It may not be amiss to mention briefly on the present occasion, the de- 
tails of a very remarkable communication, by Surgeon Russel, of the 73d 
regiment, formerly a pupil in this hospital. This communication was 
read by Dr. Wilson, at one of the soirees of the College of Physicians in 
London, and afterwards published in the Medical Gazette. Mr. Russel 
observes — 

" I was led, by the following circumstance, to reflect on the nature of 
1 coup de soleil ;' which, as well as I can recollect, is treated of by all 
authors, and is generally considered to be nothing more or less than true 



118 CLINICAL MEDICINE. 

apoplexy, produced by the direct influence of the sun's rays ; that its pa- 
thology is the same, and its mode of treatment similar — that is, that all 
the* efforts of the medical attendant should be directed to the head, as the 
chief, nay, almost the only, seat of the disease : and here it strikes me a 
fallacy exists, leading to erroneous principles of practice. In May, 1834, 
while I was in medical charge of the 68th regiment (a tine corps, com- 
posed of men in robust health), then recently arrived at Madras, the fune- 
ral of a general officer took place ; to which, unfortunately, the men were 
marched out at an early hour in the afternoon, buttoned up in red coats 
and military stocks, — at a season, too, when the hot land winds had just 
set in, rendering the atmosphere dry and suffocating even under shelter 
of a roof, and when the sun's rays were excessively powerful. The con- 
sequence was, that after proceeding two or three miles, several men fell 
down senseless. As many as eight or nine were brought into hospital 
that evening, and many more on the following day ; three died — one on 
the spot, and two within a few hours. The symptoms observed (and they 
were alike in these three cases) were, first, excessive thirst, and a sense 
of faintness ; then difficulty of breathing, stertor, coma, lividity of the 
face, and in one, whom I examined, contraction of the pupil. The re- 
mainder of the cases, in which the attack was slighter, and the powers of 
reaction perhaps greater, or at all events sufficiently great, rallied ; and 
the attack in them ran on into either an ephemeral or more continued form 
of fever. The symptoms of these three cases did not more closely resem- 
ble each other than did the post-mortem appearances. The brain was, 
in all, healthy ; no congestion or accumulation of blood was observable ; 
a very small quantity of serum was effused under the base of one, but in 
all three the lungs were congested even to blackness through their entire 
extent ; and so densely loaded were they, that complete obstruction must 
have taken place. There was also an accumulation of blood in the right 
side of the heart, and the great vessels approaching it." 

Since our last meeting, some cases of fever have occurred in our wards, 
which have presented too many points of interest to be passed over with- 
out any observation. A very curious case occurred here, in a man named 
Toole, who was admitted on the 4th of January. This patient is a robust 
labouring man, about thirty years of age, and had been labouring under 
maculated fever for ten or eleven days before admission. Of his history 
previous to admission we could learn nothing ; but when he came under 
our care he appeared very ill, and exhibited great depression of the vital 
energies, so that we found it necessary to encourage reaction by the appli- 
cation of heat to the surface of the body, frictions, warm fomentations, 
and the internal administration of wine and carbonate of ammonia. On 
the following night reaction became established ; next day he became 
irritable and restless, and towards night was seized with delirium. The 
nurse omitted to report his state to Mr. Parr, or the resident pupil ; he 
was thus left without any treatment until next morning. Now, this is a 
matter of much regret to me, and I think I cannot do a more essential 
service to those who are about to enter on the practice of their profession 
than to impress, as strongly as I can, the indispensable necessity of watch- 
ing fever patients with the most anxious and unremitting diligence. In 
a. case of bad fever a single visit in the day will never suffice ; two, and 
even three visits will be required ; and when the patient is in a doubtful 
or dangerous condition, it will be often necessary to have a properly edu- 



FEVER. 119 

cated medical person in constant attendance, prepared to meet every 
emergency, and counteract or modify every unfavourable change. Fever 
will often run on for several days without any change calculated to arrest 
our attention, or call for the adoption of any new measures, and yet, in 
the space of six hours, an alteration may occur, of which the physician 
should have early and full information. 

Well, this man remained without any treatment for several hours after 
delirium commenced. On the sixth we ordered his head shaved and 
leeched, and prescribed tartar emetic, in doses of a quarter of a grain, 
every second hour. Next day we found him as bad as ever. The tartar 
emetic had failed in diminishing the cerebral symptoms, and his delirium 
had rather increased. We found also on inquiry, that he had had no 
sleep for the last three nights. His pulse was weak and rapid, his eyes 
suffused, his restlessness and delirium such that he required a person to 
sit by him constantly, and prevent him from getting out of bed. Under 
these circumstances, we ordered five drops of black drop to be added to 
each dose of the tartar-emetic mixture, of which he took an ounce every 
third hour, that is, about a quarter of a grain of tartar emetic. He took 
four doses of this during the night ; and next morning we found that the 
delirium and sleeplessness continued still unabated, and that the man was 
sinking fast into a state of stupor and insensibility. He neither answered 
questions, nor put out his tongue when desired ; he had subsultus, and 
was muttering to himself with great volubility and rapidity of utterance. 
Indeed, his condition was such that I had no hope. Among other symp- 
toms, I should mention that he had contraction of the pupils, a symptom 
of very unfavourable augury in fever. Having failed with tartar emetic 
alone, and afterwards with tartar emetic in combination with opium, I had 
now to seek for some other means of subduing cerebral irritation, and in 
this emergency had recourse to the use of turpentine — a remedy which I 
was inclined to adopt in preference to any other, as there was some ful- 
ness of the abdomen, and other symptoms indicating the existence of con- 
gestion of the intestinal mucous membrane. I therefore ordered two 
drachms of the spirit of turpentine to be made up into a draught with a 
little oil and mucilage, and administered every second hour. 

I was guided here by a knowledge of the fact, that turpentine exercises 
a very remarkable influence over many forms of nervous irritation. I 
can refer for illustration to many affections of the nervous system charac- 
terised by excitement, in which turpentine has been employed with the 
most signal benefit. Thus, we frequently find it a most valuable agent in 
the treatment of chorea, of epilepsy, and of the convulsive fits of children. 
We have frequently experienced benefit from its use in the treatment of 
spasmodic affections of the stomach and bowels ; in hysteria, tympanitis, 
and the subsultus of fever, we often derive from it the most rapid and 
effectual relief. You recollect a case of typhus which was lately under 
treatment in our wards, and of which one of the most prominent symp- 
toms was general and continued subsultus ; and you have all witnessed 
how much relief the patient obtained from small doses of oil of turpentine. 
Hence I was led to conclude that it might be employed with benefit in 
the latter stages of fever, where vascular excitement is greatly abated, 
and where the most prominent symptoms are irritation of the nervous cen- 
tres, with more or less congestion of the gastro-intestinal mucous mem- 



120 CLINICAL MEDICINE. 

brane.* In this case, however, I must confess I used it as a last resource, 
and did not anticipate the very striking results which followed so unex- 
pectedly. After the second or third dose the patient had two or three 
full motions from the bowels, and shortly afterwards fell into a sound and 
tranquil sleep, from which he awoke rational and refreshed. He is now 
wonderfully improved in every respect, and I have no doubt that his con- 
valescence will go on favourably. f 

There is one symptom in this man's case which is worthy of your atten- 
tion, as connected with the history of fever, although in other respects it 
does not seem to possess much importance. I allude to the bulla?, which 
have appeared on the calves of his legs, on the inside of his ankles, and 
on the soles of the feet. This affection seems to belong to that class of 
eruptive diseases which are occasionally observed during the course of 
idiopathic fevers, particularly those which have arisen from the introduc- 
tion of an animal poison into the system. Thus we sometimes find an 
eruption of pustules, sometimes of vesicles (as the miliary) ; occasionally 
we have bullee, and not unfrequently erysipelas. 

We have had another case of spotted or eruptive typhus, in a man 
named Henry Harpur, which has exhibited in the strongest manner the 
value of a combination of tartar emetic and opium in diminishing cerebral 
irritation, and bringing about a favourable change in cases characterised 
by symptoms of alarming and imminent danger. Those who have wit- 
nessed Harpur's case will confess that few cases could present a more 
unpromising appearance. He had violent delirium, requiring the restraint 
of a strait waistcoat, a furious aspect, suffusion of the eyes, constant raving 
and muttering, and perfect sleeplessness. His pulse was weak, thready, 
and rapid ; his tongue and lips parched, fissured, and black; his breathing 
quick and irregular ; and his cerebral symptoms of such intensity as to 
leave little or no ground for hope. In addition, he had continued and 
general subsultus, and constant irregular motions of the extremities. Now 
this man had been rescued from a state of the most imminent danger, and 
restored to convalescence by the use of tartar emetic and opium. Those 

* [Dr. Wood, of the Pennsylvania Hospital,is also a strong advocate for 
the use of the oil of turpentine in continued fever, but rather in typhoid 
fever than in the proper typhus. He uses it in doses of five to twenty drops 
every two hours, and, as he thinks, with almost universal advantage, when- 
ever, during the cleaning process of the tongue or " after its completion, the 
surface of the tongue becomes quite dry, and the process, if not finished, 
is suspended. At the same time there is generally an increase of the 
tympanitis, and an aggravation, or certainly no abatement, of the other 
symptoms." As the case improves, the quantity of the oil of turpentine 
is diminished, but it is not suddenly given up. — W. W. G.] 

•}• Whenever any particular line of treatment is advocated, it is better, perhaps, to quote the 
opinions of others in its support rather than adduce examples from our own experience; it is 
therefore on this account I extract the following passage from the work of a celebrated writer, 
in which the line of practice adopted in the case above mentioned is spoken of in terms of 
approbation. 

"This substance (spirit of turpentine) is especially indicated where, with the abdominal 
distension and intestinal affection, there is also delirium or coma; and is equally beneficial in 
a relaxed as in a constipated state of the bowels." The author quotes the case of Toole, and 
relates one which occurred in his own practice very similar." — Copelatvd's Medical Diction- 
ary, page 930. 



FEVER. 121 

who saw the case two days since, and who have noticed the remarkably 
improved state of the patient to-day, will agree with me in saying that so 
favourable a result could scarcely be expected. In this case the tartar 
emetic and opium were combined with musk and camphor. Where great 
subsultus tendinum is present, in addition to the usual symptoms of cere- 
bral excitement, I am in the habit of combining musk and camphor with 
tartar emetic, in the following form : — 

R. Mucilaginis gummi arabici, ^ss. ; syrupi papaveris albi, J$j. ; antimonii tartarizati, gr. ij. ; 
camphors, gr. xv. ; moschi, ^ij. ; aquae fontis, ^jivss. M. 

The camphor should be previously triturated with a few drops of alco- 
hol, and the whole must be rubbed up into the form of an emulsion, of 
which a tablespoonful is to be taken every second hour, until copious 
discharges of fluid yellow fecal matter take place — an occurrence always 
attended by much relief of the cerebral and nervous symptoms, and which 
marks the period at which we ought to desist from the further use of tartar 
emetic. In the case which we are now considering, the medicine was 
administered in draughts, each of which contained half a grain of tartar 
emetic, ten grains of musk, five grains of camphor, and about ten drops 
of laudanum. After taking three such draughts, the patient fell into a 
quiet sleep, which continued for several hours. He awoke quite rational ; 
and since that period his improvement has been steady and progressive. 
I have not time to enter any further into the particulars at present, and 
merely allude to it as one of those instances in which we have succeeded 
in allaying symptoms of cerebral excitement, where the state of the patient 
afforded very little grounds for any hope of a favourable termination. 

At my next lecture I purpose to lay before you, in detail, the history 
of the results which have attended the employment of tartar emetic and 
opium in fever, with some observations on its value as a therapeutic 
agent, and on the cases to which it is most peculiarly adapted. 



LECTURE XII. 



On the efficacy of tartar emetic and opium in fever, with much cerebral disturbance ; illustrated 

by cases. 

At my last lecture I alluded to the use of tartar emetic in the treatment 
of the cerebral excitement and determination to the head, which are so 
frequently witnessed in the advanced stage of the present epidemic, 
typhus ; I shall now proceed to mention some of the beneficial effects 
derived from this plan of treatment, as illustrated by cases which have 
recently occurred in my own practice, or in that of other members of the 
profession. 

Did I bring forward this plan of treatment as infallible, or if I boasted 
that it never failed, then indeed you might well doubt my judgment in 
recommending it to your notice, for infallible remedies never earn the 
sanction of experience ; but such is not the fact. This treatment we our- 
selves have seen will not always succeed ; nay, we must acknowledge 
that it has occasionally disappointed us, even where we seemed justified 
in calculating upon success. But, gentlemen, we must recollect that 



122 CLINICAL MEDICINE. 

every useful remedy is subject to the same charge, and that in the long 
list of therapeutic agents, there does not exist a single medicine which is 
fairly entitled to the appellation of a true and infallible specific. 

We have failed in several cases with tartar emetic, either alone or 
combined with opium and other medicines, and patients labouring under 
typhus have fallen victims to cerebral disease, although we applied the 
remedy with all due diligence. Yet I think it but fair to observe, that 
most of the instances in which we failed were cases that had come under 
our notice at an advanced stage of fever, and where the cerebral symptoms 
had been wholly overlooked or improperly treated in the commencement 
of the disease. I may observe also, that cases of this description, in 
which the cerebral symptoms have been permitted, before admission 
into hospital, to form themselves fully, are exceedingly difficult to manage, 
and terminate fatally at a much earlier period than the ordinary cases of 
typhus observed in private practice. 

Maculated typhus with determination to the head, when improperly 
treated, terminates not unfrequently about the tenth, eleventh, or twelfth 
day ; sometimes it is protracted to the thirteenth or fourteenth, but most 
usually it ends fatally about the eleventh or twelfth. In neglected cases, 
the cerebral symptoms frequently assume a fearful violence on the seventh, 
eighth, or ninth day, and in such instances it must be expected that the 
best and most appropriate plan of treatment will fail in rescuing the patient 
from impending dissolution. If, however, we can find out a remedy, 
which, in many cases, apparently desperate, succeeds in rescuing the 
patient from the jaws of death, we must be satisfied. A case of this 
description has occurred since our last meeting. It has excited the atten- 
tion of all who witnessed it, as well from the violence of the symptoms, 
and the apparently hopeless state of the patient, as from the rapidity with 
which the exhibition of the remedies employed was followed by a striking 
and decided alteration in the symptoms. Any one who saw him yesterday, 
would scarcely recognise him as the same individual to-day. 

This man, named Fogarty, was admitted about the seventh or eighth 
day of his fever, according to the account of his friends. Of course in 
such cases we cannot give implicit credence to those loose statements, for 
the lower class of persons in this country never calculate the time during 
which the patient remains out of bed struggling against the disease — a 
period which, in a people inured to suffering and privation, frequently 
lasts three, four, or even six days. Well, this man, aged five-and-twenty, 
and of rather robust constitution, was admitted on the 20th of December, 
being then about eight or nine days ill. Previous to admission he had taken 
purgative medicines, had his head shaved, and six leeches applied behind 
his ears, or to his temples, I forget which. Now, all these measures, al- 
though perhaps insufficient, were extremely proper, and must have produced 
more or less benefit. W T hen we examined him on the 21st, we found 
him in a state of high excitement, as manifested by continued mental 
wandering, incessant talking and raving, and frequent attempts to get out 
of bed. He had illusions of the senses of sight and hearing, consisting of 
terrific ocular spectra,* and alarming sounds, which threw him into a state 

* In a former lecture I mentioned that analogous symptoms result from increased or dimi- 
nished sanguineous pressure on the brain ; the ocular spectra in Fogarty's case evidently 
depended on determination of blood to the head, but in the case of a lady, the wife of an emi- 
nent physician, a continued and varied succession of spectral illusions formed one of the chief 
symptoms, produced by exhausting hemorrhage after delivery. 



FEVER. 123 

of intense agitation ; his eye was red and watchful, and he never slept. 
Here then was a very threatening array of symptoms, — perfect insomnia, 
ocular spectra, illusions of the sense of hearing, a fiery eye, and incessant 
mental wandering. To this was added, great derangement of the whole 
nervous system ; his body was agitated from head to foot by continual 
tremors, and he had violent and persistent subsultus; his respiration was 
interrupted, suspicious and irregular, amounting at one time to forty in 
the minute, and a few minutes afterwards not exceeding twenty-five ; the 
acts of inspiration and expiration were extremely unequal, and occasion- 
ally accompanied by blowing and whistling. In a former lecture, I made 
some observations on this form of respiration, which I termed cerebral, 
from having first observed it in persons subject to apoplectic attacks, 
either before or during the paroxysms; it is frequently observed in bad 
cases of fever, and is a symptom of the greatest importance. He also lay 
constantly on his back ; his pulse 120, soft, and very weak, so that the 
canal of the artery could be obliterated by very slight pressure ; his pupils 
were somewhat dilated ; tongue parched and brown in the centre, red at 
the edges and tip ; skin covered with maculse ; abdomen soft and full. 
Those who have witnessed the case will acknowledge that the picture I 
have drawn is not too highly coloured, but, on the contrary, falls far 
short of the reality, and no doubt you all expected that if we did not suc- 
ceed at once in arresting the progress of his symptoms, the case must 
have proved rapidly fatal. Observe the position in which we were placed. 
In the commencement of the fever, certain appropriate but inadequate 
remedies had been employed, and, under a treatment proper but insuffi- 
cient, the disease had progressed; it was an example of one of the worst 
forms of fever, characterised by intense cerebral excitement, and accom- 
panied by total want of sleep, persistent delirium, and excessive disturb- 
ance of the nervous functions ; all these symptoms had come on gradually, 
and arrived at their acme at a period when the low and debilitated state 
of the patient precluded the use of depletive measures to such an extent 
as to exert any efficient control over the most dangerous symptoms. 
The application of a few leeches would be extremely hazardous, and 
blistering would have been wholly useless and nugatory, for before a 
blister could rise the man would be dead. For these reasons, we con- 
cluded that the only remedy we could have recourse to with any prospect 
of success was tartar emetic. We therefore ordered a draught composed 
of two drachms of mint w T ater, two of common water, and a quarter of a 
grain of tartar emetic, to be given every hour until it produced some 
decided effect on the constitution. You will recollect, here, that the scale 
was vibrating between life and death, that it was necessary that our plan 
of operation should be at once prompt and prudent, decisive and cautious. 
One of the pupils promised to stay by him the whole day and watch the 
effects of the remedy, and I determined to visit and examine him personally 
irrthe afternoon. In the course of four hours he took four doses of the tartar 
emetic ; the first and second, in fact almost every dose vomited him, but 
not immediately. He retained each dose for a considerable time, and 
then threw it up. After the fourth dose, it began to act on his bowels, 
and then the medicine was suspended for some time, and a small quantity 
of porter administered. When I saw him at eight o'clock in the evening, 
he had been freely purged, and had discharged a considerable quantity of 
bilious yellow fluid from his bowels. He had also enjoyed about an hour's 



124 CLINICAL MEDICINE. 

sleep ; his respiration was now more uniform and natural ; his raving 
greatly diminished ; the subsultus and tremors were nearly gone, and the 
man appeared quite tranquil. I then ordered him a wine-glassful of 
porter, with two drops of black drop, to be repeated every second hour 
for three or four turns successively. I saw T that the cerebral symptoms 
Were evidently diminished, and that there was a tendency to returning 
tranquillity and repose, and I wished toTollow up and assist the operations 
of nature. To-day this man is in a most favourable state. His skin is 
covered with a profuse warm perspiration, he has slept well, belly soft 
and natural, respiration slow and regular, and pulse diminished in fre- 
quency ; he is calm, rational, and composed, and I think I am not too 
sanguine in anticipating for him a speedy and certain recovery.* 

Tt is alwajs an unpleasing and ungracious task for any individual to be 
obliged to come forward w r ith proofs of the originality of his contributions 
to science : this task some have endeavoured to impose on me, and have 
sought to impugn both the originality and utility of my method of using 
tartar emetic and opium in typhus fever. Their arguments do not require 
any answer, and may be passed over in silence without any loss to you 
or prejudice to me, for certainly you could derive little profit from hear- 
ing the statements of my opponents, and I but slight credit from their re- 
futation ; suffice it then to say, that the prescriptions filed by the apothe- 
caries of Dublin establish my claims, for you will search in vain among 
them for one bearing a date prior to the publication of my papers on the 
use of tartar emetic and opium in the advanced stages of fever, and in w T hich 
these medicines are prescribed in the way, or in any thing like the way, 
recommended and practised by me. Since that date, such prescriptions 
have daily become more numerous, and I am proud to bear testimony to 
the general liberality of the profession, for the greater number of my 
brethren have not merely tried my plan of treatment, but have acknow- 
ledged its utility, and have hastened to assure me that until my publica- 
tions they had not seen it practised. But enough of this, let us not em- 
ploy in general encomiums that time which may be more profitably dedi- 
cated to instructive details ; let us therefore again recur to facts. 

I have within the last fortnight received from Mr. Burke and Dr. Beau- 
champ the notes of an extremely interesting case of this description. Mr. 
Burke is remarkable for his professional ability and his attention to his 
patients, and of Dr. Beauchamp I may state, that his experience in fever 
is most extensive. The case is extremely valuable as having been ob- 
served by Mr. Burke from the commencement ; I shall read the w ? hole of 
it from his letter, as it is well worthy of attention. 

" I was called on the 25th of November to see Mrs. M., a married 
woman, without family, of a weakly and nervous habit, though generally 
enjoying good health. She complained of having had chilliness on the 
preceding day ; and now, that she was hot, thirsty, had pain in the head 
and back, and great debility. On examination I found that petechise 
covered the chest and abdomen ; the eyes suffused ; face red ; scalp hot ; 
pulse 110, small and hard ; tongue covered with a creamy exudation ; no 
abdominal or chest affection ; secretions and excretions arrested. She 
was ordered some aperient medicine, and directed to be kept very quiet. 

" 26th. — Passed rather an uneasy night, frequent startings ; some rav- 
ing ; complains of headache, and that the light and noise are distressing ; 
* He recovered rapidly and completely. 



FEVER. 125 

pulse as before, face more flushed, bowels open. I directed a cooling 
lotion for the head, and a diaphoretic mixture containing liquor, acetatis, 
ammonia, and nitre. On the 27th, she complained of the headache being 
made worse by the noise in the house, from which I determined to have 
her removed, and I therefore did not put any active treatment into requi- 
sition. 

" 30th. — This day she was removed to a quiet airy room. I then had 
her head shaved, eight leeches applied behind the ears, and a blister to 
the nape of the neck ; bowels opened by enemata. 

" Up to the 5th of December, which was the tenth day of her illness, 
she went on tolerably well, occasionally raving at night ; tongue dry and 
red ; pulse very weak, 100 ; eyes much suffused ; face occasionally 
flushed, then pale; scalp hot. At this period Dr. Beauchamp saw her, 
and from the weakly habit of the patient, and the peculiar tremulous feel 
of the pulse, lie thought it advisable to let her have some weak chicken- 
broth and light negus ; the latter had soon to be discontinued on account 
of the excitement it produced. 

" On the 14th day she became more delirious and somewhat unmanage- 
able, though previously very gentle ; however, when spoken to she an- 
swered tolerably reasonably. Ordered to continue the lotion, enemata, 
and saline draughts. t 

" Dr. Beauchamp and I saw her next day about ten o'clock in the fore- 
noon, being the fifteenth day of her fever. Previous to one going into 
the room, the nurse gave us a frightful picture of the way she spent the 
night. She had been perfectly unmanageable, continually screaming and 
imagining she saw frightful apparitions, and had been convulsed during 
the night. On entering the room, we found her with her hands outstretched 
and rigid ; a mixture of wiidness and terror in her face, her eyes red and 
protruded, pupils contracted, pulse not to be counted, and scarcely to be 
felt ; feet cold and stiff. When spoken to she made no answer, but kept 
her eyes steadily directed towards the foot of the bed. Her aspect was 
altogether frightful, and Dr. Beauchamp observed that her state appeared 
to be a combination of delirium with hysteria. 

" The question now was, what were we to do ? We dared not apply 
leeches, blisters would be doubtful, and the probability was that the pa- 
tient would sink before they vesicated. There was no indication for cold 
to the head, for the scalp was cool. Could we rely with safety on ner- 
vous medicines ? their very stimulus might hasten her to the tomb. The 
indication was to relieve the brain, and the question was, what medicine 
or combination of medicines would effect this safely ? Under these cir- 
cumstances, we happily thought of the treatment employed by you in 
somewhat similar cases. We immediately ordered a mixture containing 
three grains of tartar emetic, half a drachm of laidanum, and six ounces 
of water: of this a tablespoonful was administered every half-hour, its 
effects being watched. We saw her again at one o'clock on the same 
day, and had the pleasure of finding her much improved. She had taken 
three doses, and vomited twice. The expression of her countenance 
was much changed, it had lost its ferocity and wiidness ; her tongue was 
now moist, perspiration was beginning to appear over her body, the pulse 
was soft and about 100, and the intelligence, which had been absent for 
a considerable period, now reappeared. She was able to answer our 
questions, and expressed herself relieved. We ordered the medicine to 



126 CLINICAL MEDICINE. 

be continued, giving a tablespoonful every hour. After taking two doses, 
she became perfectly quiet, fell into a profound and tranquil sleep, per- 
spired copiously, and at our visit next morning at ten o'clock, we found 
her, to our astonishment, almost well. She looked cheerful and refreshed, 
and spoke of the wonderful relief she obtained ; her pulse was soft, and 
about 80 ; her skin natural, her tongue moist and clean. Dr. Beauchamp 
did not think it necessary to continue his visits, and all that remained for 
me was to conduct her by proper regimen from convalescence to perfect 
health. She is now quite well. 

u It is a source of gratification to me to have had the able assistance of 
Dr. Beauchamp on this occasion, and his presence during the eventful 
period adds much value to the case. Dr. B. remarked at the time when 
hope had fled, that he knew of no routine of practice which afforded a 
probability of being of service, so that we may fairly conclude, that but 
for your happy combination the patient must have died." 

This is a very strong case, indeed there could scarcely be a more strik- 
ing illustration of the value of tartar emetic and opium in the treatment 
of the cerebral symptoms of fever. The case too was one of great danger, 
the patient was of a nervous weakly habit, and during the acme of the 
disease she had an attack of convulsions. This is a very important and 
most formidable symptom in fever, particularly when superadded to others 
indicating a deranged state of the sensorium. We had a patient here, 
some time back, who had two convulsive paroxysms during the course of 
his fever, and you recollect that I told you that it was a symptom of un- 
usual danger. Some time ago a gentleman, in discussing my cases, said 
that convulsions in fever were not so dangerous, but I had the satisfaction 
of quoting for him the authority of Hippocrates, to show that persons who 
have been attacked in this way very seldom recovered. 

I shall conclude this lecture by detailing a very remarkable case, which 
has been communicated to me very recently in a letter from Mr. Swift : — 

" J. Kinsela, a labourer, aged 23, of powerful make, and robust con- 
stitution, was attacked with fever about the 14th or 15th of January. He 
complained during the ensuing week of intense headache, thirst, and de- 
bility, but had no medical treatment. On Saturday, the 21st, he was ex- 
tremely ill and restless, and on Sunday morning, while his clergyman and 
several of his friends were with him, he got out of bed in a state of furious 
delirium, seized a knife, and having cleared the room, rushed out into 
the street in his shirt, where he was secured by a policeman and some of 
his neighbours, and brought back to bed, having previously wounded 
several of his captors in the struggle. He then fell into a state of coma, 
and when I saw him on the following Thursday, the 26th, he exhibited 
the following symptoms : — Decubitus on the back ; eyes nearly closed ; 
lips red, dry, and chapped ; forearms bent and agitated by apparently 
unconscious movements; convulsive twitches of the eyebrows and angles 
of the mouth ; breathing irregular, heavy, and somewhat stertorous (of 
that description which you have aptly termed cerebral), pulse oppressed, 
unequal, weak, and about 110 ; great heat of scalp and face ; temperature 
of the body normal ; feet very cold. He had no pulmonary symptoms ; 
his belly was soft and apparently natural, but he gave indications of un- 
easiness when firm pressure was made over the situation of the stomach 
and small intestine. He was raised up in bed, shaken roughly, and spoken 
to repeatedly, but gave no answer ; nor would he put out his tongue, or 



FEVER. 127 

open his eyes when requested. His tongue, as far as I could see it, ap- 
peared red, dry, crusted, and fissured ; and on raising his eyelids, I found 
the eyes greatly suffused, and the pupils contracted nearly to the size of 
a pin's head. 

" His face, hands, and head were bathed with warm vinegar and water, 
jars filled with hot water applied to his feet, and about two o'clock, p.m. 
he commenced taking tartar emetic in doses of a quarter of a grain every 
hour. It was combined with a small quantity of opium. 

" When I saw him again, about nine o'clock in the evening, he was 
wonderfully improved. He could be easily roused, answered questions 
distinctly, put out his tongue when desired, and appeared quite rational. 
He had taken about two grains of the tartar emetic, the effects of which 
appeared to be chiefly confined to the circulating system. His pulse was 
now equal and regular, the temperature of his body nearly uniform, and 
a slight degree of moisture could be felt on his skin, but he was neither 
vomited nor purged. A mixture, containing nitrate of potash and tinc- 
ture of hyosciamus, was substituted for the tartar emetic ; the fomenta- 
tions of warm water and vinegar were continued, and he had a purgative 
enema with turpentine, which was followed by a full discharge from the 
bowels and copious diuresis. On Saturday, the 2Sth, he had an indis- 
tinct but favourable crisis ; his tongue became clean and soft, and his 
pulse diminished in frequency. On the following Tuesday, his pulse 
w T as 76, his tongue clean, eyes clear, pupils natural, appetite returning, 
so that I considered it unnecessary to continue my visits beyond the fol- 
lowing day. His convalescence is now completely established. 

" I have been particular in describing ihe cerebral symptoms in this 
case, as the patient's head was neither shaved, blistered, nor leeched. 
A portion of his hair was cut off'with a scissors, and this was all that was 
done in addition to what I have mentioned. I attribute his recovery to 
the tartar emetic and opium, as under its use he recovered in a few hours 
from a state of stupor and coma, which otherwise must have speedily ter- 
minated in death, and I think this valuable remedy has additional claims 
to notice, if (as it would appear from Kinsela's case) it can be employed 
as a substitute, for all the ordinary and expensive remedies used on such 
occasions, — remedies, which in dispensary practice, and among a pauper 
population like ours, it is often difficult, and sometimes impossible to pro- 



LECTURE XIII. 

On bed-sores in fever, and their treatment — Instances of fever spreading by contagion — Attack- 
ing a person whose mouth was affected by mercury — Observations on the use of tartar 
emetic in fever — An account of the manner in which it is usually employed — New views 
upon this subject — Treatment of fever with profuse sweating in the commencement — Mr. 
Cookson's case — Mr. Stephenson's case — Mr. Knott's case. 

A woman has been admitted lately who had been labouring under fever 
for a considerable time before she came into the hospital. This poor 
creature seems to have been in very miserable circumstances during her 
illness; her bedding must have been totally neglected, and no attention 
paid to cleanliness, for on her admission, though nearly free from fever, she 



128 CLINICAL MEDICINE. 

was covered with bed-sores to a frightful extent. Almost every point 
which had been subjected to pressure had ulcerated, and the ulcers went 
on undermining the skin, and committing terrible devastation in the cel- 
lular substance. Cases like this require great care and unremitting atten- 
tion ; it is on the exercise of an active and untiring humanity that the 
cure will mainly depend. In the first place, you are to recollect that the 
efforts of the constitution towards the re-establishment of health are im- 
peded by the irritation of the sores ; sleep is prevented, and the patient 
kept in a state of continual suffering, while a constant drain from the sys- 
tem is kept up by the ulcerative discharge adding to the amount of ex- 
isting debility. Hence a pseudo-febrile state arises, characterised by 
quick pulse, restlessness, and want of sleep, somewhat akin to that which 
is produced by scrofulous irritation. The appearance, however, of gene- 
ral excitement of the system should never prevent the physician from 
adopting every mode of strengthening the patient as much as possible. 
You will not succeed in removing this condition by an antiphlogistic regi- 
men ; the patient requires tonics and narcotics with a nutritious but not 
stimulating diet. If you put him on a low regimen, and give anti- 
febrile medicines, you will do mischief, you will increase the existing 
debility, and add to the source of febrile excitement. Your practice 
should be to prescribe a nutritious diet, wine, and the sulphate of quinine, 
and to treat the sores with stimulant applications. The local application 
which we found most beneficial in such cases, is one composed of tw T o 
ounces of castor-oil, and one of balsam of Peru, which is to be applied 
on pledgets of lint, and covered with a poultice of linseed meal two or 
three times a-day. In addition to this, we direct the sores to be washed 
night and morning with a solution of chloride of soda, in the proportion 
of twenty or thirty drops of the saturated solution to an ounce of water. 
We also direct the patient to lie occasionally on her face, and enforce the 
strictest attention to cleanliness on the part of the nurse. Dr. Arnott's 
hydrostatic bed is an excellent adjuvant in the treatment of this disease, 
but unfortunately the one we have is at present out of order. 

Such, then, is our mode of treatment. We order the patient nourish- 
ing, but not heating food ; we give wine, regulating its quantity according 
to its effects on the system, and the liking of the patient ; we prescribe 
small doses of the sulphate of quinine, and administer an opiate at night 
to allay irritability and procure sleep. The local treatment consists in 
the use of stimulant and detergent applications, poultices, attention to 
cleanliness and change of position. 

With respect to the present epidemic fever,* we have now seen so many 
instances of its direct communication from one point to another in our 
wards, that we are induced to believe it to be contagious. From the 
great number of applicants labouring under serious and threatening dis- 
eases, we are sometimes obliged to put into our fever wards, patients 
affected with local inflammations, accompanied by symptomatic inflam- 
matory fever ; several of these, while recovering, have been attacked with 
symptoms of the present epidemic. A man was admitted last week into 
the fever ward with violent pneumonia ; the right lung was extensively 
hepatised, and, in addition to this, the pleura was found to be engorged 
over a large portion of its surface. The case was one of extreme distress, 
and the state of the patient apparently hopeless ; however, by appropriate 

* This lecture was delivered in 1834. 



FEVER. 129 

depletion, assisted by mercury and blisters, convalescence became estab- 
lished, and the pulmonary symptoms were rapidly subsiding. His sys- 
tem was still under the influence of mercury, his lever had disappeared, 
his dyspnoea was relieved, his cough, and all the other symptoms, nearly 
gone, when he was suddenly attacked with fever, and that of the same 
character as prevailed among the patients in the same ward. This is, I 
believe, the sixth or seventh case, in which patients labouring under 
some other form of disease, have been seized with symptom* of the pre- 
sent epidemic, while lying in the same ward with fever patients. I have 
thought it necessary to make this observation, because you will find it 
asserted in medical works, and by physicians of considerable eminence, 
that in hospitals fever does not spread from one patient to another, and 
that where it does appear among many individuals in the same house, its 
spread is chiefly favoured by want of cleanliness and proper ventilation. 
This, however, we can state to be the fact, that fever will spread among 
patients in the same ward, independent of any thing connected with filth 
or foul air, for we have seen it occur in our wards, which I can assert are 
kept as clean, and as well ventilated, as any in the kingdom. 

There is one circumstance connected with this case worthy of remark, 
with reference to the supposed antifebrile properties of mercury. It has 
been stated that mercury exercises a prophylactic influence over the 
system, and several persons who have cultivated medicine with success, 
but particularly some army surgeons, of high authority, have asserted that 
the use of mercury not only cures fever, but also secures against it. I am 
afraid that in this and other cases, mercury has more credit than it de- 
serves. In speaking of cholera, on a former occasion, I have told you 
that 1 had seen persons under the influence of mercury take cholera and 
die of it ; and here we find a man, whose mouth is still sore, in whom 
salivation had not ceased, getting an attack of fever at a time when he 
had just recovered from another disease. This shows that mercury is not 
to be looked upon as a prophylactic Hi cases of fever of a contagious 
nature. We cannot always cure or prevent fever with mercury ; on the 
contrary, where fever of a particular kind is present, it prevents the con- 
stitution from yielding to its influence. Thus, in a case of hectic fever, 
brought on by suppuration of the liver, it has been found impossible to 
bring the system under the influence of mercury. 

In a preceding lecture, when speaking of the best means of procuring 
sleep in various forms of acute disease, I alluded to the peculiar narcotic 
power of the preparations of antimony, and dwelt on the benefits derived 
from a combination of antimonials with those medicines which are strictly 
termed narcotics. I told you in that lecture that the good effects of tartar 
emetic in delirium tremens seem to be totally independent of its action 
on the stomach ; for we had witnessed those effects when it had not ex- 
cited either nausea or vomiting. I referred also to many instances of 
delirium tremens, in which opium in every form had failed in procuring 
sleep, and where a combination of tartar emetic and laudanum had suc- 
ceeded in tranquilismg the patient and producing sound, refreshing sleep. 
Bearing this important fact in mind, we shall proceed to an examination 
of the circumstances which require the use of tartar emetic in fever. 

There is a peculiar stage in one form of fever, and that exceedingly 
dangerous and threatening, in which I have derived most signal benefit 
from the use of this remedy. A patient, suppose, gets an attack of fever, 
10 



130 CLINICAL MEDICINE. 

he has all the ordinary symptoms, as thirst, restlessness, heat of skin, 
quick pulse, and headache. You are called in about the third or fourth 
day, and find that he has all the symptoms I have mentioned still present; 
his face is flushed, his head aching, his pulse from 100 to 110, but not 
remarkably strong ; you find, also, that he has been sweating profusely 
from the commencement of his illness, but without any proportionate relief 
to his symptoms, and that he is restless and watchful. You are informed 
that his perspirations are so great that his linen has to be changed fre- 
quently in the day, and that, notwithstanding this, the pulse has not 
come down, the headache is undiminished, and the patient has become 
more and more sleepless. Here comes a very important practical ques- 
tion, namely — How are you to treat such a case ? The patient has no 
epigastric tenderness, no cough, no sign of local disease in either the 
thoracic or abdominal cavities; he has been purged, used diaphoretics, 
and perhaps mercurials ; every attention has been paid to regimen, ven- 
tilation, and cleanliness ; but still he lies there in a state of undiminished 
febrile excitement, with persistent headache, quickness of pulse, and 
sleeplessness. 

In such a case as this you have nothing to expect from the sweating; it 
will never produce any relief. I was called some time back to see a young 
gentleman in fever, who was placed in similar circumstances to those which 
I have just detailed. It was about the sixth day of his fever, and I found 
him w T ith a pulse of about 110, with considerable restlessness and head- 
ache, and was informed that he had perspired profusely from the commence- 
ment of his illness. On hinting the necessity of more active treatment than 
that w T hich had been employed, his physicians appealed to the perspira- 
tions as decidedly contra-indicating depletion. They said that the pro- 
fuse sweating pointed out the impropriety of active measures, and that it 
was a symptom which would be speedily followed by relief. I was con- 
vinced that they had taken a wrong view T of the case, and stated as my 
opinion that nothing was to be expected from the perspirations; that when 
co-existing with a persistent febrile condition of the system, when accom- 
panied by quick pulse, headache, and restlessness, perspirations always in- 
dicated the necessity for antiphlogistic measures, and in particular for the 
use of the lancet. I instanced the case of patients labouring under arthritis 
with profuse perspirations not accompanied by relief, and said that it was 
well known that such cases were most successfully treated by a full bleed- 
ing from the arm. I accordingly stated that although the disease w r as of 
five or six days' standing, and the pulse not very strong, I would advise 
immediate bleeding. Sixteen ounces of blood were therefore abstracted, 
with some relief to the patient, and without increasing his debility; and 
it was then a question what further steps were to be taken. The young 
gentleman had been actively purged ; he had no cough or abdominal ten- 
derness: his symptoms were headache, sweating, and sleeplessness; and 
to these, nervous agitation had now become superadded. I proposed here 
what surprised my colleagues very much, and this was, to give our patient 
large doses of tartar emetic. They said the practice w 7 as very strange, but 
consented to give it a trial, on laying before them the reasons which in- 
duced me to prescribe it. I said that in such cases the tartar emetic, form- 
ing as it w T ere a part of the antiphlogistic treatment which commenced with 
general bleeding, would have a tendency to cut short instead of increasing 
the perspiration, by reducing the inflammatory state of the system on which 



FEVER. 13 L 

it depended. The reasoning seemed rather paradoxical — nevertheless it 
turned out to be correct. I ordered the tartar emetic to be taken in the 
quantity and mode in which it is generally prescribed in acute pneumonia, 
that is to say, six grains of tartar emetic combined with a little mucilage 
and cinnamon water in an eight-ounce mixture, to be taken in the course 
of twenty-four hours. After taking five or six grains, the sweating began 
to diminish; on the second day he scarcely perspired any, and his head- 
ache was greatly relieved; he began to improve rapidly in every respect, 
sleep returned, nervous agitation ceased, and convalescence became soon 
established. 

The next case in which I employed tartar emetic with signal benefit was 
one of a very insidious character, as many of them are at present; they 
exhibit no prominent or alarming symptoms, and yet continue to run on 
day after day without any tendency to crisis. The gentleman who was 
the subject of this case got an attack of fever, unaccompanied by any re- 
markable peculiarity, except that he was very nervous, and alarmed about 
his situation. His fever went on day alter day without any decided symp- 
tom; he had no distressing headache, no cough, little or no abdominal 
tenderness," there was no vomiting or diarrhoea; and his pulse was not 
much above the natural standard. He had been leeched over the stomach 
at the suggestion of some medical friends, but this was done rather by the 
way of precaution than for the purpose of combating any actual disease. 
About the eighth or ninth day the pulse began to rise ; he complained of 
headache, and became restless and watchful. On the eleventh day the 
headache had greatly increased, he was in a state of great nervous excite- 
ment, and had not closed an eye for the two preceding days and nights. 
This state of insomnia and nervous agitation was immediately followed by 
violent paroxysms of delirium; his eyes never closed in sleep, wandered 
from object to object with unmeaning restlessness; his limbs were in a state 
of constant jactitation, and he raved incessantly ; his voice being occasion- 
ally loud and menacing, at other times low and muttering. His friends 
became exceedingly alarmed, and every remedy which art could suggest 
was tried: — his head was shaved and leeched until they could leech no 
longer; cold lotions were kept constantly applied with unremitting dili- 
gence, and he w T as purged freely and repeatedly. At this period, that is 
to say, about the eleventh day of the fever, I was requested by this gentle- 
man's medical friends to visit him. On examining the patient, I found 
that he was constantly making violent efforts to rise from his bed, and that 
he had a great deal of the expression of countenance which belongs to a 
maniacal patient. Under these circumstances, I advised the use of large 
doses of tartar emetic, in the mode already detailed, except that, in this 
case, in consequence of the violence of the delirium, I ordered the quantity 
prescribed for a dose to be taken every hour instead of every second hour. 
The patient took about ten or twelve grains during the course of the night, 
and next day his delirium had almost completely subsided. Under the 
use of the remedy he became quite calm, fell into a sound sleep, and began 
to recover rapidly. 

In the two preceding cases I was guided by ordinary principles, recog- 
nised by all physicians, and according to which the exhibition of tartar 
emetic is recommended in fever, whenever there is undoubted evidence 
of determination of blood to the head, producing headache, loss of sleep, 
and delirium. In the cases which follow, tartar emetic was exhibited at 



132 CLINICAL MEDICINE. 

a period of fever, and under circumstances that were, with respect to the 
exhibition of this remedy, not less novel than important. The principles 
which led me to this practice have long been established, but, neverthe- 
less, the practice is entirely new, and (I say it with pride, for it has already 
been the means of saving many lives) it is entirely my own. 

Shortly after the commencement of our present session, Mr. Cookson, a 
pupil at this hospital, and remarkable for his diligent attention to clinical 
pursuits, caught fever w 7 hile attending our wards, in which many cases of 
the present epidemic were then under treatment. His fever was of an 
insidious nature, not characterised by any prominent symptom, nor exhi- 
biting any local disease to combat, or any tendency to crisis. For the 
first seven or eight days, with the exception of headache, which was much 
relieved by leeching, he seemed to be going on very well ; his skin was 
not remarkably hot ; he had no great thirst, nausea, or abdominal tender- 
ness ; his pulse was only 85 ; and he had sweating, which was followed 
by some relief. About the eighth or ninth day the pulse rose, and he 
began to exhibit symptoms of an hysteric character. Now, in every case 
of fever, where symptoms resembling those of hysteria come on, you 
should be apprehensive of danger. I do not recollect having ever met 
with a single case of this kind which did not terminate in nervous symp- 
toms of the most formidable nature. I prescribed at the time the usual 
antihysteric medicines, but without any hope of doing good, knowing 
that these symptoms w T ere only precursory to something worse. I also, 
as a precautionary measure, had leeches applied to his head. The fever 
went on, the headache became more intense, he grew nervous and sleep- 
less, and fell into a state of great debility. On' the fourteenth day of fever 
his tongue was black and parched, his belly tympanitic; he was passing 
every thing under him unconsciously ; he had been raving for the last four 
days, constantly attempting to get out of bed, and had not slept a single 
hour for five days and nights. Dr. Stokes, with his usual kindness, gave 
me the benefit of his advice and assistance at this stage of Mr. Cookson's 
illness, and we tried every remedy which experience could suggest. 
Blisters were applied to the nape of the neck, the head was kept cool by 
refrigerant lotions, the state of the belly attended to, and, as we perceived 
that the absence of sleep was a most prominent and distressing symptom, 
we were induced to venture on the cautious use of opium. It w T as first 
given in the form of hydrarg. c. creta, with Dover's powder, with the 
view of relieving the abdominal symptoms as well as procuring sleep. 
This failing in producing the desired effect, we gave opium in the form 
of enema, knowing its great power in the delirium which follows wounds 
and other injuries. This was equally unsuccessful with the former. He 
still was perfectly sleepless. We came again in the evening, and as a 
last resource, prescribed a full dose of black drop, and left him with the 
conviction that if this failed he had no chance of life. On visiting him 
next morning at an early hour, we were highly mortified to find that our 
prescription had been completely unsuccessful ; he had been more restless 
and delirious than ever. Here was the state in which we found him on 
entering his chamber at eight o'clock in the morning of the fifteenth day 
of his fever. He had universal tremors and subsultus tendinum, his eye 
was suffused and restless, he had been lying for some days entirely on his 
back, his tongue was dry and black, his belly tympanitic, his pulse 140, 
quick and thready, his delirium was chiefly exhibited in short broken 



FEVER. l-:3 

sentences and in a subdued tone of voice ; and it was now eight days and 
nights since he had slept. Here arose a question of great practical im- 
portance. How was the nervous agitation to be calmed and sleep pro- 
duced ? Blisters to the nape of the neck, cold applications, and purgatives 
had failed ; opium in various forms had been tried without the slightest 
benefit ; if sleep were not speedily obtained he was lost. At this emer- 
gency a mode of giving opium occurred to me which I had never thought 
of before. Recollect what his symptoms were at this period : quick, fail- 
ing pulse, black, dry, tremulous tongue, great tympanitis, excessive pros- 
tration of strength, subsultus tendinum, extreme nervous agitation, con- 
stant muttering, low delirium, and total sleeplessness. I said to Dr. 
Stokes that I wished to try what effects might result from a combination 
of tartar emetic and opium : I mentioned that I had given it in cases of 
delirium tremens with remarkable success, and thought it worthy of trial 
under the circumstances then present. Dr. Stokes stated in reply, that 
he knew nothing with respect to such a combination as adapted to the 
case in question, that he had no experience to guide him, but that he 
would yield to my suggestion. We therefore prescribed a combination of 
tartar emetic and laudanum in the following form, which is that in which 
I generally employ the remedies in the treatment of delirium tremens. 
&. Antimonii tartarizati grana quatuor, tinct. opii. drachmam,misturaecam- 
phorae, ^viij. Of this mixture, a tablespoonful was to be taken every se- 
cond hour. Thesuccess of thiswasalmost magical. It istrue that it vomited 
him ; after taking the second dose he threw up a large quantity of bile, but it 
did him no harm. After the third or fourth dose he fell asleep, and awoke 
calm and refreshed ; he began to improve rapidly, and soon recovered. 

The next case to which I shall direct your attention is that of Mr. 
Stephenson, a pupil of Mr. Parr of this hospital. This young gentleman, 
as many of you will recollect, was attacked with fever about the middle 
of January. On Thursday evening he complained of languor and malaise, 
and on the following day felt himself feverish, but without any prominent 
or decided symptom. At night he took a dose of calomel and antimonial 
powder, which had no sensible effect, and the following day complained 
of shivering, violent headache, pain in the back, thirst, prostration of 
strength, and sleeplessness. He was ordered to take a combination or" 
tartar emetic and nitrate of potash in camphor-mixture, which produced 
a few loose stools and some diaphoresis ; but in consequence of its effect 
on the stomach, and his complaining much of thirst and epigastric tender- 
ness, the tartar emetic was omitted, and effervescing draughts prescribed. 
Two days afterwards, the epigastric tenderness still continuing, twelve 
leeches were applied over the pit of the stomach, followed by blister, 
which gave relief, and the bowels were kept open by enemata. He com- 
menced a second time the use of the tartar emetic and nitrate of potash, 
with the addition of five drops of tincture of opium to each dose, but was 
obliged to give it up again in consequence of the increase in his gastric 
symptoms. He now became exceedingly restless, and his delirium began 
to assume a very intense character. Leeches were applied behind the 
ears, his head shaved, and his temples blistered ; he had also a large 
blister over the abdomen, which gave him considerable relief, but the 
cerebral and nervous symptoms became much worse. The delirium went 
on increasing, accompanied by subsultus tendinum, and picking the bed- 
clothes ; he was perfectly sleepless ; raved incessantly, and had to be kept 



134 CLINICAL MEDICINE. 

down in bed by force. On the 17th day of his fever he was in the fol- 
lowing condition — tongue brown and rather dry, no remarkable thirst or 
abdominal tenderness, eyes red and ferrety, no sleep for five nights, con- 
stant muttering and delirium (which had now assumed the character of 
delirium tremens), subsultus tendinum and jactitation extreme, urine and 
feces passed under him unconsciously. I directed the combination of 
tartar emetic and laudanum to be immediately given, carefully watching 
its effects. He had only taken two doses when a degree of calmness set 
in, bringing with it relief to all his symptoms, and before a third dose 
could be administered, he fell into a profound sleep, from which he awoke 
rational and refreshed. The mixture was continued every four hours 
with increasing benefit, he slept long and soundly, and began to improve 
in every respect. On the second day after he had begun to use the tartar 
emetic, he took a little porter, which was changed the next day for claret 
and chicken-broth. In about a week he was able to sit up in bed, and 
seven days afterwards was able to leave the hospital and go to the country 
for change of air. 

The last case to which I shall direct your attention is that of Mr. Knott, 
also a pupil of this hospital, a gentleman remarkable for his unremitting 
attention to clinical pursuits, and from whom I derived much valuable 
assistance in conducting various post-mortem examinations. This gen- 
tleman was attacked with fever about the latter part of January, which 
went on for some time without any particular symptom, except consider- 
able restlessness and nervous excitement. He then became perfectly 
sleepless, complained of violent headache and thirst, raved, and became 
exceedingly irritable. Opium in various forms and repeated doses, either 
alone or combined with musk and camphor, totally failed in producing 
sleep, and his condition became daily worse. On the 13th day he was 
in a very dangerous condition ; his nervous agitation had risen to an 
alarming height, and for many days and nights he had never closed an 
eye. At this period it appeared obvious that if something were not done 
to calm nervous excitement and restore sleep, he had but little chance of 
life. Under these circumstances I proposed to my friend, Dr. M'Adam, 
who attended with me, to give tartar emetic and opium. After he had 
taken about three tablespoonfuls, he had a copious bilious evacuation, 
and immediately afterwards fell into a sound sleep, during which he 
perspired profusely, and awoke in about twelve hours, with every 
bad symptom gone. The nervous irritability was completely allayed ; 
his thirst and headache relieved ; his tongue moist and cleaning ; and 
his reason quite restored. From that period every thing went on favour- 
ably, and he rapidly gained his health and strength. 

Since the foregoing lecture was delivered, I have met with several 
cases of fever, in which I emplryed the tartar emetic and opium with 
the same remarkable success. A man named Christopher Nowland was 
admitted into Sir P. Dun's Hospital, on the 3d of February last, labouring 
under fever. He had been ill ten days, had raving, subsultus tendinum, 
and appeared unable or unwilling to answer questions. His wife stated 
that he had diarrhoea for the preceding three days, and that he dozed 
occasionally, but never slept. He appeared exceedingly low and pros- 
trated, and lay constantly on his back. A succession of flying blisters 
were ordered to be applied to the chest and stomach, and wine and 
chicken-broth prescribed. He also got the following draught every third 
hour : — 



FEVER. 135 

R. Mist, camphorae, %j. 

Spirit, setheris oleosi, ^ss. 
Spirit, ammonise aromaticae, gss. 
Moschi, gr. viij. — Misce. 

Under the use of these remedies he began to recover from his prostration; 
but as the sleeplessness and delirium still continued, I ordered him to 
take the tartar-emetic mixture in the usual way. It produced at first two 
or three full discharges from the bowels, and after he had taken the fourth 
dose he fell into a sound sleep, from which he awoke much better, and 
soon became convalescent. 

In the case of a patient named Michael Murray, who exhibited the same 
remarkable nervous irritability and sleeplessness, this remedy was also em- 
ployed with very striking effects. This man had been ill of fever for ten 
days before his admission into Sir Patrick Dun's Hospital, and appeared 
so much prostrated that I ordered him arrow-root with beer. He raved a little 
on the night of his admission, and remained without closing an eye until 
morning. The same symptoms were observed on the following day, and 
his nervous irritability became increased. On the 14th of February he had 
been five days in the hospital, and had not enjoyed a single hour's sleep. 
I ordered the tartar-emetic mixture to be given : three doses produced 
sleep: he had no other bad symptoms, and recovered completely. 

In another very bad case of maculated fever, the same results were ob- 
tained. The patient, Mary Farmin, had got an attack of fever after a 
fright. She had been eight days ill at the date of her admission, February 
25th. She had irregular pulse, sleeplessness, headache, and suffusion of 
the eyes; moaned and sighed continually, and appeared greatly prostrated. 
She was blistered, had fetid enemata, and took the chloride of soda inter- 
nally with some benefit; but the sleeplessness and nervous excitement con- 
tinued. In this case, though the tartar emetic was not followed by speedy 
convalescence, still it produced remarkably good effects; after taking four 
doses of it she fell asleep, and did not awake until next morning. 

There are many other cases which I could adduce to prove the value 
of a combination of tartar emetic and opium in the nervous sleeples>ness 
of low fever; the foregoing, however, I trust, will be found sufficient. 

I forgot to observe, that all the cases I have spoken of as successfully 
treated by means of tartar emetic combined with opium in the advanced 
stage of the disease, were cases of maculated or spotted fever. 



LECTURE XIV. 

General account of the spotted fever epidemic in Dublin, in 1S34-5 — Its most remarkable 
features — Insidious character — Further explanation of the reasoning which led Dr. Graves 
to the discovery of the utility of tartar emetic in its latter stages. 

When I last addressed you, I spoke of a very important topic — the ad- 
ministration of tartar emetic in the advanced stages of spotted or maculated 
fever. A few observations descriptive of the present epidemic fever, ap- 
pear necessary. The commencement is frequently by no means violent, 
in proportion to the subsequent danger, and the patient often appears 
merely to labour under the symptoms of a common feverish cold, seldom 



136 CLINICAL MEDICINE. 

preceded by violent rigors, but attended by a frequently recurring sense 
of horripilation. The pulse in the very beginning, seldom exceeds 90, 
and in nearly half the cases it falls after a few days to 80, 70, or even 
lower. This slow pulse I observed in many of the pupils, and in all it 
was found to accompany a very tedious and dangerous form of fever. 
Mr. Sangster, Mr. Graves, Mr. Harris, and Mr. O'Flaherty, were all so 
affected ; for none of these gentlemen had a pulse exceeding 70 in a minute, 
for many days before the period of the greatest danger. In other epi- 
demics similar cases have occasionally occurred, but in none near so fre- 
quently as in the present. When the pulse was thus tranquil, the skin 
was not perceptibly hotter than natural, although occasionally a slight de- 
gree of the cator mordax could be detected. Patients with a slow pulse 
not unfreqnently had little to complain of at first; for the headache, gene- 
ral pains, thirst, and restlessness, generally underwent a notable diminu- 
tion, in consequence of sweating which came on in the commencement — 
the appearance and the good effects of which were well calculated to de- 
ceive the practitioner into a belief that the fever had terminated. A more 
accurate examination, however, showed that this was not % the case; for 
the tongue still continued much loaded, white in the centre and red at the 
tip, and the apparent subsidence of the fever was found to be accompanied 
by a remarkable increase of debility. As the disorder proceeded, a slight 
rash, like ill-defined or suppressed measles, became observable in some 
before the fourth day, but much oftener about the seventh. This macu- 
lated appearance of the skin increased rapidly, spreading over all parts of 
the trunk and extremities, and in many amounted to a well-marked efflo- 
rescence of a dusky red colour; in others it was as it were suppressed, and 
was less obvious, but was still discernible by an experienced eye, appear- 
ing beneath as if veiled by the skin. It was not totally absent in one case 
out of twenty, which induced me to name the disease maculated fever. 
So the patient continued, in general, until the ninth, tenth, or eleventh 
day, resting sufficiently at night, with a moderate or even a slow pulse, 
some thirst, foul tongue, little or no nausea, epigastric pain, or abdominal 
tenderness of any sort, and, in fact, without a single symptom calculated 
to excite alarm. About this period of the complaint matters began to as- 
sume a more threatening aspect; debility manifestly increased; the mind 
at times was evidently incoherent, particularly after awaking from sleep, 
and then raving during the night ; restlessness ; frequent attempts to get 
out of bed very generally supervened in the course of a few days. The 
pulse, meantime, rose very suddenly in many, and continued to be fre- 
quent during the period of danger. Thus, on the tenth day, Mr. Syms's 
pulse rose from 85 to 120, and so continued until about the twentieth day, 
when improvement commenced. The same sudden rising of the pulse 
took place on the ninth day in Mr. M'Namara, and he died on the four- 
teenth day. In others, as I have already remarked, the pulse continued 
tranquil throughout. Thus, it was v-ery curious to see a patient with a 
skin of a natural temperature, a perfectly natural pulse, tranquil respiration, 
clear eye, no headache, a soft and fallen abdomen, without the slightest ten- 
dency to epigastric tenderness ; it was very curious, I say, to see such a 
patient in a state, nevertheless, of extreme danger, passing both feces and 
urine under him; raving, incoherent, or with a low muttering delirium ; 
subsultus daily increasing until it became excessive; the greatest possible 
degree of debility; a dark macular efflorescence, and at length total sleep- 



FKVER. 137 

lessness. How many theories of fever were refuted by such a case ! 
Usually, as the disease continued, and when the patient was in a very dan- 
gerous state — but seldom or never before that — the intestines began to be 
inflated, and the belly gradually became tympanitic; a circumstance of bad 
omen, and which was often the precursor of hiccup. When the symptoms 
did not yield to the efforts of nature or of art, the congestion of the intes- 
tinal mucous membrane, indicated by these symptoms, was soon followed 
by indubitable evidence of cerebral congestion — such as restlessness, suf- 
fusion of the adnata, and contraction of the pupils; this last was the most 
fatal of all symptoms. In two or three cases — as, for instance, that of Mr. 
Cookson — the cerebral congestion produced repeated fits of convulsions 
on the thirteenth day, and yet he recovered. The same happened in a 
young woman in Sir P. Dunn's Hospital, in whom the convulsions occurred 
on the fifteenth day, and were more violent on the right side than on the 
left, producing strabismus and insensibility of the pupil of the affected eye. 
This girl lost the use of her left side on that day, but recovered it on the 
following; and eventually, though with difficulty, was completely cured. 
Frequent fits of convulsions, affecting the right side more than the left, 
took place on the seventh day in the daughter of a clergyman residing 
in the Liberty, and were followed by a stupor bordering on coma, 
which lasted for many hours. All these patients were covered with ma- 
culae. 

I am thus particular in dwelling on the symptoms manifestly denoting 
a combination of primary general nervous excitement with a secondary 
cerebral congestion ; for, on the successive development of these states 
the treatment during the latter stages hinged. I wish you clearly to un- 
derstand, that, after the headache and cerebral excitement which accom- 
panied the very commencement of the fever had been subdued, or had 
ceased, after sleep and calm had returned, and had continued for many 
days, then a new order of things commenced — subsultus, watchfulness, 
muttering, raving, involuntary discharges, &c, — all denoted great de- 
rangement of the nervous system ; but still there was no proof that this 
derangement depended on cerebral congestion. After a few, or after 
many days, however, unequivocal symptoms of the latter set in ; the face 
and eyes became suffused and flushed ; the pupils manifested a tendency 
to become contracted, and occasionally convulsions took place ; the pa- 
tient became totally sleepless. When the latter and dangerous period of 
the fever was accompanied by the former nervous group of symptoms 
alone they yielded to wine, musk, porter, and opiates ; but when the 
symptoms indicating cerebral congestion were superadded, then it was 
that the case assumed so great and striking a similarity, as far as the func- 
tions of the nervous system were concerned, to the well-known variety of 
delirium tremens, accompanied by cerebral congestion — to that variety of 
delirium tremens, in fact, which only can be successfully treated by the 
judicious but bold exhibition of tartar emetic combined with laudanum. 
It is the discovery of the utility of this practice in the adva?iced stages of 
spotted fevers, that I claim peculiarly as my own ; for there is not in the 
writings of any author on the subject, the slightest trace of such a method 
of treatment to be found. As this method has manifestly saved many, 
many lives, under a combination of circumstances apparently hopeless, I 
cannot avoid congratulating myself upon being the first to propose a prac- 
tice which has not only diminished the rate of our hospital mortality in 



138 CLINICAL MEDICINE. 

a remarkable manner,* but has been the means of saving many of my 
friends and pupils ; for, without its adoption, our class at the Meath Hos- 
pital would have been more than decimated, whereas at present we have 
to regret the loss of but one pupil. 

One word more as to the circumstances under which this plan was ap- 
plicable. They were exactly the circumstances which formerly would 
have been believed to demand the fresh application of leeches to the head, 
of cold lotions, and of blisters ; for it was formerly argued, and justly, we 
have in this advanced stage of fever not merely debility to combat — not 
merely general nervous excitement to overcome — but we have also to con- 
tend with cerebral congestion. The latter is the most formidable of the whole : 
let us meet it boldly ; let us leech, let us purge, &c, &c. I need not repeat 
to you the details of cases illustrating the ill effects of this practice. Suffice 
it to remark, that you might as well attempt to cure delirium tremens with 
mere leeching, purging, and blistering. Observe, I am now speaking of 
the advanced stages of fever ; for where cerebral congestion takes place 
in the beginning or the middle of fever, then is there no room for opium 
— then will the practitioner have recourse to the well-known, remedies for 
active cerebral congestion ; viz., purging, leeches, cold lotions, ice to the 
head, &c, &c. In the preceding sketch of the present epidemic, many 
important features have been omitted. The outline is only complete in 
such parts as were required to be filled up for the purpose of illustrating 
the principles which directed me in devising and employing this new plan 
of treatment. I shall conclude these observations with a few details of 
Mr. Thomas O'Flaherty's case. 

This young gentleman was seized with the usual symptoms of maculated 
fever, of an insidious character, and not attended with any appearance of 
danger during the commencement of the disease. His pulse never rose 
above 100, and before the seventeenth day of the fever, it had fallen to 
70, at which it remained during the period of greatest danger. The only 
circumstance which excited alarm in my mind, at an early period of his 
illness, was a great degree of mental apprehension manifested in his anti- 
cipating an unfavourable result, together with a tendency to sleeplessness 
from the beginning. On the tenth, abdominal tympanitis was observed, 
but this was removed in two days by appropriate remedies. On the 
tw T elfth day he was very restless, and although he was perfectly rational 
in his answers to questions, and did not complain of headache, nor had 
flushing of face, or heat of the integuments of the head, yet he frequently 
talked incoherently when left alone, and towards the latter part of the day 
began to make repeated attempts to get out of bed. On one occasion he 
succeeded, and walked down stairs, from his bed-room to the parlour. 
His tongue was brown and dry. Under these circumstances, I ordered 
him the mixture containing four grains of tartar emetic and one drachm 
of laudanum, in eight ounces of camphor-mixture ; of this he took 5ij- 
every second hour. The effects produced by this medicine were not very 
rapid, but still they were decidedly beneficial, for he gradually became 
calmer, wandered less, did not attempt to get out of bed, and, during the 

* Seventy-three fever patients — namely, forty-one males and thirty-two females, were treated 
in the clinical wards at Sir P. Dun's Hospital during the months of February, March and 
April. Of the?e, more than fifty were cases of maculated or spotted fever, and yet we lost but 
two females and one male. The latter was in a hopeless condition when brought in, and one 
of the former was attacked by varioloid just after the crisis of long-continued spotted fever. 



FEVER. 139 

night, got some sleep. His bowels being confined, the mixture was now 
laid aside, and purgatives exhibited : I should have remarked that the 
tartar-emetic mixture caused profuse sweating. On the fifteenth day of 
the fever, his bowels having been acted on, he was ordered twenty drops 
of Battley's solution of opium at night, which produced a comfortable 
night's rest, the first he had enjoyed since his illness. On the sixteenth, 
the sweating continued, belly was fallen, and he was quite rational, but 
had marked subsultus ; he got another dose of Battley, but it produced 
no sleep ; he had been allowed chicken-broth, beer, &c, for some days. 
On the seventeenth day, the sweating had ceased, and his skin had be- 
come hot and dry ; great restlessness, constant muttering, delirium, sub- 
sultus, tremors, picking the bed-clothes, involuntary discharges. Porter 
in small quantities, chicken-broth, fetid injection, and twenty drops of 
Battley at night. On the eighteenth, he was reported to have had no 
stool from the injection, and no sleep whatsoever. He answered inco- 
herently, thought his bed was covered with lancets, some of which he 
collected carefully, and reserved for me ; belly not tumid, but obstinately 
confined ; pulse 100. The whole of that day, and the following, were 
employed in procuring alvine evacuations, preparatory to again giving 
opium ; in the mean time, all his symptoms were aggravated, and when 
I visited him on the evening of the nineteenth day, his state was anxious 
in the extreme, as he had enjoyed no sleep for many days and nights, 
and was in a melancholy state of mental incoherence, raving, tremor, and 
subsultus. Here came the crisis as to treatment. I remember well the 
time when a patient so situated would have been again purged, his head 
would have been shaved, a few leeches applied to the temples, and a 
blister to the nape of the neck, while perhaps wine and musk would have 
been exhibited internally. How many persons have I seen so treated by 
the most eminent physicians, and how unsuccessful was the practice ! 
To have talked of giving opium under such circumstances, and when the 
marks of cerebral congestion were so evident, would have been regarded 
absurd ; my experience on former occasions, however, determined me to 
give opium, and, as the danger was imminent, I gave it boldly. To the 
eight-ounce mixture, with four grains of tartar emetic, we added one 
drachm and a half of laudanum ; of this he took one ounce every second 
hour, from eight in the evening until he had taken five doses. This pro- 
duced copious sweating ; the skin became cooler, he raved less, but still 
no sleep ; at four on the following morning, his pulse became 70, and re- 
spirations tranquil ; he got twenty drops of Battley, and at half-past five 
in the morning, twenty-five drops more. He had now tak«m, within a 
short time, about one drachm of laudanum, and forty-five drops of Battley, 
combined with nearly three grains of tartar emetic. He was tranquil, but 
did not close his eyes, ami muttered occasionally ; subsultus less. His 
pupils now became more and more contracted, his eyes less expressive 
and duller, and when I came at eight in the morning, he was evidently 
deeply narcotised, although not yet asleep. I thought that all was lost ; 
but still, observing the respiration to be tranquil, and the pulse regular, I 
indulged a faint hope that sleep might still supervene. His eyes now 
became still more inexpressive, the lids gradually closed, his breathing 
became prolonged and deep, and at half-past eight he was buried in a 
profound and tranquil sleep, which continued for nine hours, when he 
awoke, spoke rationally, said he had no pain in the head, took some 



*40 



CLINICAL MEDICINE. 



drink, and fell asleep again. Next morning not a single symptom of 
fever remained. 

I need scarcely observe, that the proportions of the two powerful medi- 
cines which compose this mixture must vary according to the circum- 
stances of the disease, and the age of the patient. In young persons of 
tender age, the opium must be given in smaller quantities. 

In conclusion I shall only mention, that since this practice was first 
proposed, it has continued to afford me the greatest satisfaction, and that 
I have reason to believe that those who have employed it in this country, 
and at the other side of the channel, have had no reason to lose confidence 
in it. 

In a paper on typhus fever, by Dr. Kilgour, we find that the experience 
of Dr. Dyce, of the Aberdeen Infirmary, is strongly in favour of this prac- 
tice. He says, "For months together the pulmonic symptoms prevailed 
almost entirely, then came those marked by gastric and intestinal irrita- 
tion, and less often, though still continuing for a length of time in suc- 
cession, those with high cerebral action. The first set, as is too well 
known, were by far the most intractable and fatal ; the last, though suffi- 
ciently alarming, and always requiring restraint, were more amenable to 
treatment than either of the others, if anticipated in their approach, or 
seen soon after their onset. By the way, the medicine I solely relied on 
in this latter class, you do not include among your list — 1 mean tartar emetic 
given as described by Dr. Graves ; I have found it eminently successful, and 
have the greatest confidence in it." — Edin. Med. and Surg. Journal, No. 
cxlix. Nov., 1841. 

And in the Eleventh Volume of the Dub/in MedicalJournal, the reader 
will find an interesting paper on "Certain Remedies in Typhus Fever,'' 7 by 
Dr. Hudson, of Navan. Speaking of the treatment by tartar emetic and 
opium, he says, " It seems best adapted to that restless kind of delirium 
tremens, in which the patient cannot be restrained from attempting to 
leave his bed, and walk about his ward ; when every muscle is tremulous, 
the eye is red from want of sleep, the tongue dry, and the patient pre- 
senting that kind of spurious excitement w T hich might induce the attendant 
(injudiciously, no doubt) to order the local abstraction of blood, by leech- 
ing the temples, or opening the temporal artery. I could here give re- 
ports from my note-book of several cases thus treated, but that I consider 
it would be rendering tedious a paper already too long. In prescribing 
this medicine, I find it advisable to use great caution in two ways : 1st, 
Not to give it after it has produced sleep ; 2d, To follow it up by the 
prompt and frequent exhibition of wine, and such nourishment or cordials 
as the more or less advanced stage of the disease, and debility of the pa- 
tient may require ; as it seems to me that there is increased risk of the 
patient sinking unless timely supported after sleep thus induced." 

There is one circumstance connected with this epidemic, but which I 
have also frequently witnessed in other sporadic and epidemic fevers, to 
which I wish forcibly to draw your attention ; it is the existence of ten- 
derness generally over the body ; and which causes the patient to shrink 
from the pressure of the finger, applied to any part of the integuments. 
This tenderness arises from an irritated state of the nervous system gene- 
rally, and is usually accompanied by severe dorsal or lumbar pain, indi- 
cating spinal congestion. Now, in a practical point of view, this tender- 
ness requires attention ; for if it be overlooked, and if the physician applies 



FEVER. 141 

pressure, in such cases, only to the epigastrium, he will be dcr^irecl ii-'o 
the belief that the tenderness lie there discovers is confined to that part, 
and indicates the application of leeches to the pit of the stomach. 

Having spoken so much of the salutary effects of opium in certain 
stages of fever, it may not be irrelevant to our subject to introduce to 
your notice a remarkable case of violent enteric inflammation, attended, 
as such cases always are when exceedingly intense, with cholera-like col- 
lapse in the very onset of the disease. This case was saved by means of 
thirteen or fourteen grains of opium, given in the course of twenty-fours, 
a plan of treatment which I first proposed, add which has since been very 
generally adopted. 

I shall take the liberty of reading to you the following letter, from my 
friend, Dr. Nolan. 

" My dear Doctor, — The following is an abstract of my notes upon the 
case of my servant Horan : — 

" On Monday evening, 27th February last, he casually complained of 
pains in his bowels ; they had not been freed on that day, and supposing 
it an instance of mere indigestion, I ordered him five grains of calomel, 
and a draught of castor-oil. For that night I heard no more of him, but 
early on the following morning I was hastily summoned by one of his fel- 
low-servants, who reported that he was dying. I found him labouring 
under severe but intermitting pain of the belly, particularly about the 
umbilicus, violent and frequent cramps, especially in the lower extremities, 
and occasional vomiting. The surface was perfectly cold ; features 
sunken ; eyes surrounded by a dark areola ; voice subdued to a whisper ; 
pulse 140, small and feeble; abdomen tender, though not at all tumid. 
He told me he passed the night in great torture, and that the bowels were 
still unmoved. I immediately ordered ten grains of calomel, to be fol- 
lowed in two hours by an oil and turpentine draught, a turpentine enema, 
bathing, &c. 

u Three hours subsequently — temperature restored ; cramps less violent ; 
vomiting less frequent, but bowels obstinate ; face and pulse equally unpro- 
mising as before ; abdominal pain increased. Was this incipient inflamma- 
tion ? And what is the cure for inflammation ? Bleeding? Well, I did bleed ; 
but scarcely had four ounces been taken, when I was very glad to tie up the 
arm ; the prostration alarmed me. Something, at all events, ought to be done, 
and I ordered a sinapism to the abdomen, a repetition ot the enema (for I 
confess I have not much confidence in frequent or powerful purgatives), a 
powder, composed of calomel two grains, opium quarter of a grain, to be 
taken every fifteen minutes. Towards evening, I thought my patient 
rallied a little ; his countenance was better ; pulse firmer ; his abdominal 
pain not increased, and he vomited but once ; the injection brought away 
with it a little mucus but no more. Repetat haustus terebinth. Repetat 
quoque enema. During the night, there was just a trace of feculent mat- 
ter, but vomiting returned, and I found him in the morning (the second 
of his illness) suffering an increase of pain ; the abdomen, too, was now 
not only extremely tender, but decidedly swollen ; the pulse remained 
quick and weak as ever. I could not discover that he passed water. 
Would you not call this inflammation ? But would you bleed for it ? I 
did, unfortunately, to as great an extent as I could, which was about eight 
ounces, and the cadaverous look, the cold clammy surface, in short, the 



142 CLINICAL MEDICINE. 






absolute collapse which succeeded, and continued for hours, gave me 
strong reason to regret it. It produced no impression upon the pain. I 
had read, with great interest, the invaluable observations of yourself and 
Dr. Stokes, as well as the publications of Armstrong, Griffin, Gooch,&c, 
w ? hcrein the applicability of opium, to certain modifications of abdominal 
inflammation, is forcibly demonstrated, and I thought my patient precisely 
in the condition in which you would probably have had recourse to that 
powerful agent. I therefore commenced exhibiting half a grain of opium, 
and two of calomel, every half-hour. After the second hour, I substituted 
for the calomel three grains of carbonate of ammonia, which, with the 
opium as before, I continued during the day and the whole night. In the 
morning (the third) I had the satisfaction of ascertaining that the pain and 
swelling had considerably subsided, and that the bowels had been twice 
opened ; his countenance now spoke promisingly, and pulse began to fall. 
I, however, persevered in my plan of treatment for the day, and, indeed, 
for the two following nights and days (gradually increasing the interval 
between each dose, however), until all trace of pain and obstruction had 
disappeared. The bowels continued to act from time to time, although I 
never ventured upon another purgative ; the dejections w r ere at first 
largely mixed with blood and mucus, but soon assumed every character 
of health. Of the sequel (may be the consequence) of this interesting 
case, you most kindly undertook the management, and I shall add nothing 
to this meagre statement of facts, which Mr. O'Donnel, (of Keane's in 
Suffolk Street), to whose humanity and care I am deeply indebted, wit- 
nessed as well as myself. I shall leave you to speculate upon the pro- 
priety of bleeding at all, under such circumstances. I shall also leave 
you to decide whether the increase of inflammation, which certainly 
occurred when I first gave up the opium plan (on the first night) for the 
sake of interposing a purgative, was to be attributed to the change or not. 
May not the case throw some light on the abuse or use of purgatives? 
But I am doing more than I intended, and more than is useful. 

" I remain, my dear Doctor, 

" Yours most truly, 

"J. Nolan. 
" April 19, 1835.— 10, College Green." 



APPENDIX. 

FURTHER OBSERVATIONS ON THE USE OF TARTAR EMETIC IN THE DELIRIUM 

OF FEVER. 

[The two following papers on the use of Tartar Emetic and Opium in 
Fever, were published subsequent to the appearance of my lectures in 
London, in the 9th vol. of the Dublin Medical Journal; I shall therefore 
make no apology for introducing them in this place.] 

ARTICLE I. 

The subject of the following observations is treated at some length in 
the preceding lectures, and I have been induced to notice it again, be- 
cause subsequent experience has enabled me to collect many additional 
facts, illustrative of the practice then recommended. 



FEVRR. 143 

It is well known that delirium tremens requires very different modes 
of treatment, varying according to the constitution, strength, age, and 
habits of the patient. In the young and robust it often assumes a form 
exceedingly resembling that of delirium arising from sudden congestion 
or inflammation of the brain or its membranes, and then demands strictly 
antiphlogistic measures, such as venesection, leeching, cold to the head, 
and very active cathartics. These remedies will often speedily arrest the 
progress of the disease. On the other hand, we very frequently meet 
with delirium tremens calling for a totally opposite plan, for when it occurs 
in the old, debilitated and confirmed drunkard, who has been repeatedly 
subject to its attacks, we are often obliged to exhibit opium from the very 
commencement, and that in large doses combined with porter, punch, or 
some other cordial ; these two form the extremes, between which there 
are many intermediate varieties, each requiring a special modification of 
practice. Thus, some must be treated rather actively, on the antiphlo- 
gistic plan at first, and immediately afterwards opiates may be used with 
advantage ; while in others, opiates cannot be given alone at any period 
of the disease, so prominently marked are the symptoms of cerebral con- 
gestion ; and yet these cases cannot be cured without narcotics. How 
then are they to be exhibited ? Do we possess any medicine capable of 
modifying and diminishing their injurious effects when given where cere- 
bral congestion exists ? Undoubtedly we do ; tartar emetic will accom- 
plish this desirable object, and in delirium tremens the value of its com- 
bination with opium is recognised by every practitioner of experience. 
Tartar emetic, boldly exhibited, often is itself our sheet anchor in delirium 
tremens, especially when the evidence of active determination to the 
head is undoubted. Then tartar emetic alone, in repeated doses, often 
powerfully contributes to produce tranquillity and sleep ; but there are 
other, more mixed cases, where we cannot cure without adding opium, 
sometimes in larger, sometimes in smaller quantities, to the solution of 
tartar emetic ; and so it is with the delirium and sleeplessness, so often 
met with in continued fever. Every one is acquainted with the indica- 
tions denoting the propriety of adopting the antiphlogistic practice when 
these symptoms make their appearance in the commencement of fever. 
Then the lancet, leeches, purgatives, cold applications to the head, and 
finally, repeated doses of tartar emetic tend powerfully to reduce vascular 
action, and diminish the violence of symptoms depending on cerebral 
congestion and excitement. Here the lancet and tartar emetic are our 
best opiates, our best restoratives of tranquillity and sleep. As the 
fever progresses, and when we have arrived at a more advanced 
stage of the disease, when macula? make their appearance on the skin, 
and symptoms of general debility announcing the typhoid type begin to 
predominate, then we must proceed with more caution, even though our 
patient is totally deprived of sleep and is violently delirious. The lancet 
cannot now be resorted to ; leeches, indeed, may be applied, but their 
effects must be carefully watched, as the patient will not bear copious 
depletion of any sort ; tartar emetic may, nevertheless, still be given 
boldly, and will be found to answer our expectations. But if we have to 
contend with want of sleep and delirium at a still more advanced 
period of fever, we now often recognise that very combination o¥ symp- 
toms, the union of general debility, and cerebral congestion, which in 
certain varieties of delirium tremens we have seen so successfully treated 



144 CLINICAL MEDICINE. 

with tartar emetic and opium ; who will refuse to acknowledge the simi- 
larity between these cases of fever delirium and many varieties of delirium 
tremens ? are there not in both, the same tremor and subsultus of the 
extremities ; the same trembling of the tongue when the patient endea- 
vours to put it out ; the same starting and sleeplessness ; the same ramb- 
ling, delirium or incoherence, combined nevertheless with the power of 
answering rationally when spoken to ; the same character of the mental 
wandering, for in both they are extremely apt to rave as if employed in 
their ordinary occupations, and as if surrounded with their usual asso- 
ciates ; in short, can any greater resemblance exist between two diseases 
arising from the operation of remote causes so different ? We need not, 
therefore, be surprised, at finding the same treatment applicable to both. 

Since the delivery of the clinical lectures in which the preceding cases 
are detailed, several others have occurred both in hospital and private 
practice, to some of which I now beg leave to direct attention, observing 
that I have in every instance been particular in mentioning the names of 
other professional gentlemen who witnessed the progress of each case ; a 
precaution tending to prevent exaggeration either in detailing symptoms 
or describing the effects of remedies. 

The case of Mr. William Murphy, an extremely diligent and intelligent 
pupil at the Meath Hospital, is well worthy of notice. The father of this 
gentleman, a practitioner of well-known reputation at Fermoy, where he 
has been Physician to the Fever Hospital for many years, arrived in 
Dublin the very day his son's state appeared to be hopeless, soon after 
the consultation, when Doctor Stokes and J agreed to use the tartar emetic 
and opium ; Doctor Murphy admitted afterwards that he never felt so 
much surprised as he was at this treatment, but having intrusted the care 
of his son to us, he very properly expressed no opinion on the subject, a 
mode of proceeding he has never since ceased to congratulate himself 
on, for had he opposed us, the case was apparently so desperate, that it 
may be doubted whether we would have ventured to put the plan into 
execution. 

Mr. Murphy, aged 20, having been engaged in the diligent study of 
the fever cases in the Meath Hospital, was attacked with violent symptoms 
of fever on the 6th of January last. He took a dose of calomel and James's 
powders, and went to bed ; early next morning he was worse, and although 
he took a purgative draught which operated freely on the bowels, he 
complained much of headache, and was very feverish; a copious sweat 
broke out, but was unattended with relief, notwithstanding that it con- 
tinued with more or less interruption for several days. His thirst was 
excessive, and he was very restless, depressed, weak, and nervous ; the 
antimonial powder and calomel were persevered in during the second 
day, and on the third he took more purgative mixture, and twelve leeches 
were applied to the temples, but they gave little or no relief to the pain 
in the head. In short, he grew worse, and was found to be extremely 
prostrated. On the 4th, his tongue was foul and dry, his stomach irri- 
table, often rejecting his medicine, and producing a vomiting of bilious 
matter, the pulse quick, and his air unpromising. I saw him on the 5th 
day, when every thing was still worse, and the pain of head much com- 
plained of. I directed a continuation of the James's powder, and effer- 
vescing draughts. On the 6th day he was still worse, and was reported 
to have raved a good deal during the night ; his bowels were loose, and 



FEVER 145 

now for the first time the perspiration entirely ceased, and his skin became 
hot and drv. I gave him small doses of Dover's powder and chalk. On 
the 7th day his countenance expressed great anxiety, and in addition to 
an aggravation of all the other symptoms, his skin became covered with 
a measles-like eruption of maculae, a circumstance which induced me to 
give the liquor of the chloride of soda, in doses of twelve drops, every 
fourth hour, in an ounce of camphor-mixture. He got mild diet, as arrow- 
root and chicken-broth, with a little stale bread sopped in tea, night anJ 
morning. On the 8th day, no improvement ; much raving during the 
night. On the 9th, symptoms as before, except that the occurrence of 
some abdominal tympanites and slight epigastric tenderness induced me 
to apply six leeches to the pit of the stomach The bleeding from the 
leech-bites was moderate, but seemed nevertheless to exhaust him. It 
seemed to check the tympanitic tendency. On the 9th day, was still 
worse, much stupor, incipient subsultus ; towards evening a very hurried 
and laboured breathing supervened, and he lay entirely on his back, 
helpless and weak, respiring about 45 times in a minute. As he had not 
the slightest affection of the lungs or bronchial tubes, this hunied breathing 
excited the greatest alarm in my mind, and induced me to apply six 
leeches behind the ear, with a view of relieving the now increasing 
stupor, and the evident cerebral congestion. 

On the 10th day, 1 had the benefit of Doctor Stokes's advice. We 
found our patient in a state truly appalling. He lay panting on his back, 
restless and without sleep, every muscular fibre in his face and limbs was 
agitated with spasmodic twitches, giving rise to the greatest possible 
degree of subsultus, which distorted his face, caused him to bite his under 
lip every instant, rendered him quite unable to put out his tongue, although 
he endeavoured to do so. The subsultus prevented us from being able 
to feel the pulse, now weak and rapid, at the wrist. In the mean time, 
though he often moaned and raved, he muttered indistinctly ; he evidently 
understood what was said to him, and as far as we could collect, lie seemed 
to suffer much less from pain in his head. Still the temporal arteries 
were turgid, and his eyes suffused. He had retention of urine, and since 
yesterday it was drawn off with the catheter. What was now to be done ? 
Cold lotions to the shaved head had failed —a blister to the nape of the 
neck had proved useless — we could not venture to rely on more blistering 
of the scalp — some more powerful remedy must be instantly brought to 
bear, or our patient was lost. Alvine evacuations had been pushed to 
the fullest extent ; leeches could not even be proposed, so great was the 
debility. Opium we dared not venture on, seeing that so recently the 
pain in his head had been urgent, and that the temporal arteries and the 
conjunctiva still seemed to indicate cerebral congestion ; under these 
circumstances we resolved to try tartar emetic, and we ordered the fol- 
lowing mixture : — 

R. Tartar Emetici gr. ii. Moschi gr. xxx. Mucilaginis Syrupi Simplicis aii 5L aquae 
fontis 3X. M. Sumat 3ss. omni hora. 

After he had taken about six doses of this medicine, he seemed rather 
better, and the symptoms of determination to the head appeared less 
marked ; we therefore added fifteen minims of patent black drop to the 
remaining nine ounces of the mixture, and directed small quantities of 
porter and chicken-broth to be given repeatedly during the night. On 
11 



146 CLINICAL MEDICINE. 

the 11th day, we found a change for the better truly surprising: the pulse 
had diminished remarkably in frequency, and had become softer and 
fuller; a warm sweat had broken out, he had raved but little, and had 
slept tranquilly. We ordered a continuance of the same nourishment and 
medicines, the latter at much longer intervals ; the case need not be further 
detailed, as Mr. Murphy rapidly recovered and enjoyed a speedy con- 
valescence. Here then is a case which would assuredly have been lost 
but for the well-tried application of the new method of treatment. I say 
this emphatically, for Mr. Glyssan, Mr. Boyton, Mr. Clarke, and Doctor 
Murphy, all anxious and competent observers, assured us that from the 
moment he began the bottle, its good effects were apparent, and increased 
after each dose. 

Case II.— John Doyle, admitted into Meath Hospital, May 21st, 1835 ; 
three or four days ill, a strong young man; the symptoms were attended 
with considerable reaction at the beginning, his face being flushed, eyes 
wild, and head aching; he raved much during the night from the 4th 
day, and had then a full bounding pulse at 105. Venesection was or- 
dered, but he fainted when four ounces of blood had ^ been drawn. 
Leeches were then applied to the epigastrium. On the sixth day of his 
illness, his thirst was great, no sleep, skin moist, belly soft, pulse 120, 
pain in head severe, copious eruption of maculae. His head was now 
shaved, and six leeches applied behind the ear, and were repeated three 
times. He was ordered the liquor of the chloride of soda on the 7th day, 
as the vascular excitement had then diminished, and the maculae con- 
stituted a prominent feature in his case. On the 8th day he was not 
worse, but his skin was still very hot. On the 9th day, eyes suffused, 
face flushed, much thirst, no sleep, bowels free, belly soft, some epigas- 
tric tenderness, tongue loaded, but moist, cold lotions to the head. 10th 
day, delirium violent during the night, strait-waistcoat necessary, eyes 
suffused, belly soft, skin very hot, pulse 120, respirations 40, considerable 
subsultus. Six leeches to be applied behind the ear three times suc- 
cessively. 

R. Tart, emetici gr. iv. aquae fontis lb. i. M. Sumat ^ss. omni hora. 

11th. Slept very little, delirium less violent, one very large stool, heat 
of skin less, eruption copious. 

R. Misturee camphoree ^viii. Tartar emetici gr. iv. Tincturae opii gi. M. Sumat ^ss. 
2a q q. hora. 

12th. Slept five hours, seems better, but still he passes his stools under 
him ; pulse 120, eyes suffused, skin hot, tongue cleaning, belly soft, bow- 
els loose, maculae numerous. The same prescription, except that the 
tincture of opium was increased to jiss. in the eight-ounce mixture. 

13th. The medicine was continued for several hours, when he fell 
asleep, and slept so much and so tranquilly, that it was not thought ne- 
cessary to repeat it. Pulse 110 ; subsultus not near so violent ; does not 
rave ; knows every one, and answers rationally ; light nourishment. 

14th and 15th. Improvement continues, but still there is much fever, 
and many maculae. About the 21st day he was free from fever, but he 
got no medicine after the night of the 12th. 

This case exemplifies the treatment adapted to the three different stages 
— 1st, Bleeding, leeches, cold lotions ; 2d, Tartar emetic in large doses, 



FEVER. 147 

combined with leeching; 3d, Opium boldly administered in combination 
with tartar emetic. 

Case III. — The following, communicated by my friend Mr. Knott, 
whose own case I have already referred to, excited much interest among 
the practitioners of the neighbourhood : — 

On the 20th of July iast, I was called to see a comfortable farmer, re- 
siding near Boyle, in the county Roscommon, named J. K . He was 

aged 30 years, and had been ill 21 days. His fever commenced with 
rigor, headache, and pains in the loins, the headache being particularly 
severe. In the commencement of the fever he had raved incessantly ; 
slept but little ; had frequent retching ; his bowels were confined ; for 
these symptoms, he was purged with black bottle to excess, and bled 
largely and frequently, but without any permanent alleviation. On the 
21st day of his fever he presented the following appearance and symp- 
toms : — his countenance was expressive of great anxiety and ferocity ; his 
eyes were bloodshot and wild ; teeth covered with sordes ; tongue brown 
and furrowed with clefts ; he raved violently and attempted to get out of 
the bed several times ; great excitement and subsultus ; his skin was very 
hot and dry ; all the secretions much diminished ; urine high-coloured ; 
no eruption ; no epigastric tenderness ; abdomen slightly swollen and 
tympanitic, but pressure seemed to give no pain ; his bowels had not been 
open for three days. That night he was ordered 40 drops of the tincture 
of opium, at the same time that an enema was exhibited ; the bowels were 
once opened ; he slept none during the night, and the excitement was, if 
any thing, greater than before. Under these circumstances it was thought 
advisable to administer the tartar emetic and opium in the manner I had 
seen it exhibited, whilst acting as clinical clerk under Doctor Graves in 
the Meath Hospital. He got an ounce of a mixture, consisting of eight 
ounces camphor-mixture, four grains tartar emetic, and a drachm of lau- 
danum every second hour, and after he had taken the third dose he had 
a large watery evacuation ; after he had taken the fourth dose he fell into 
a calm sleep, in which he continued for nearly twelve hours ; he awoke 
much refreshed and covered with a profuse perspiration. He was able 
now to recognise his friends ; the subsultus and general excitement was 
greatly, but not entirely, allayed ; his pulse, which had been 120, small 
and wiry, had fallen to 98 ; he continued his medicine during the next 
night with the greatest benefit. From this period this man's recovery 
was rapid and unexpected, and at the end of three weeks he was able to 
attend to his business. 

Case IV. — {Reported by a Pupil.) — Ellen Dowden, aged 18, admitted 
in the Meath Hospital on the 8th of June, states that she has been ill 12 
days. Her illness commenced with the usual symptoms ; headache ; 
rigor ; loss of rest and appetite : previously to her admission she had been 
purged freely without any relief. On the day of her admission she was 
flushed ; skin dry and very hot ; the whole body was covered w r ith ma- 
culae ; she was heavy and stupid ; answered questions incoherently ; her 
eyes were slightly suffused ; called out continually for drink ; her tongue 
was dry, brown, and rough ; seemed to have much pain on making pres- 
sure on the epigastrium ; the belly was swelled and tympanitic ; bowels 
confined ; no cough or headache ; pulse 108, wiry ; applicentur hirudi- 
ness octo epigastrio ; head to be shaved and cold lotion to be applied. 

fi. Hydrargyri c. creta, gr. x. Pulv. ipecac, comp. gr. ii. M. Fiat. pulv. quater in die 
sumend. 



148 CLINICAL MEDICINE. 

9th. Much worse to-day ; slept for about one hour yesterday evening ; 
lies continually on her back ; seems to take no notice of what is going on 
about her ; raved occasionally during the night ; teeth and mouth covered 
with sordes ; tongue very dry, rough, and coated with brown ; pulse fallen 
to 80, very small, but less wiry than on yesterday ; her bowels were 
opened twice copiously ; belly soft and fallen ; epigastric tenderness much 
relieved, headache gone, maculae less. 

R. «oI. chloric! : sodae gtts. xv. Mist, caraph. 3L GuttsB nigree. gtt. i. M. Fiat, haust. 
quater in die sumend. 

To have a pint of beer and arrow-root. 

10th. Raved the whole night ; subsultus general and violent ; pulse 
120, sharp ; slightly dicrotous ; slept none ; face much more flushed than 
on yesterday ; eyes suffused, passed under her ; macula? much diminished ; 
has no headache ; bowels rather free ; lies on her back with her feet 
drawn up ; has no chest symptoms ; respiration natural ; ordered ice in 
bladders to the head, with a mixture composed as follows: — 

R. Mist, camph. gyiii. Tart, emetic, gr. i. M. Sumat ^ss. omni semihora. 

11th. When seen yesterday evening she was very violent ; endeavoured 
to get out of bed ; screamed loudly, and complained of bad treatment ; 
she had slept none at this period, her bowels had been freed copiously, 
but she still continues to pass under her ; she endeavours to throw the 
ice bags off her head, and requires some violence to hold her in bed ; sub- 
sultus extremely violent ; face much flushed ; eyes red ; she was ordered 
the following : — 

R. Mist, camph. ^viii. Tart, emetic, gr. iv. Tinct, opium, gi. M. Sumat Jss. secundis 
horis. 

She had taken but two tablespoonfuls when she began to sleep ; she has 
continued to doze to the hour of visit ; she is much improved in every 
respect ; she answers questions rationally ; her face is not so much flushed ; 
eyes less suffused ; has no headache ; pulse 120, not so sharp ; skin still 
very hot ; tongue moist and cleaning. She was ordered not to take any 
of the mixture if she continues better. Enema emolliens statim. Im- 
provement went on steadily until convalescence was established. 

Case V. — "My dear Doctor, — In compliance with your request, I send 
you an abstract of the case of Stephens. It was one of spotted fever oc- 
curring in a \oung man of temperate habits, setting in with languor fol- 
lowed by rigor. I saw him on the 4th day, when there was unpleasant 
heat of surface, with general tenderness all over the body, particularly 
remarkable over the epigastric region ; the chest, and hands, studded with 
florid maculae; headache and pain of back distressing; light disagreeable ; 
pulse 108 ; tongue moist. He had an oil draught, followed by small doses 
of hyd. c. cret. c. pulv. Dover. On the 6th day of his fever, being very 
restless and sleepless, eyes slightly suffused, and pulse 120, I gave him 
an eight-ounce mixture, containing four grains of tartar emetic, and a 
drachm of tincture of opium ; two tablespoonfuls to be taken in the evening, 
and one every hour afterwards. On the next day the report was, that he 
had slept a good deal during the night, having fallen asleep after the third 
dose, three hours after which a fourth was administered. He is dozing; 



FEVER. 149 

pulse 120 ; skin hot and dry ; bowels four times moved ; ordered to con- 
tinue his mixture, watching its effects. On the 8th day, in consequence 
of severe purging having set in (he had taken but two doses of the mix- 
ture since last report), the epigastrium becoming very tender, and pulse 
132, his medicine was omitted, and a cretaceous mixture ordered instead, 
a small quantity of port wine diluted, and a blister to the abdomen; the 
blister was not applied, yet the purging was checked. On the evening 
of the 9th day, as he complained much of want of rest, and there was no 
headache, I directed him to have two doses of the tartar emetic and opium 
mixture, within an interval of two hours. I was compelled at this period 
to give up attendance on this case in consequence of an accident; it was, 
however, taken up by my friend Dr. Grant, who kindly kept notes, and 
with whom I had daily conferences. He reports our patient, on the 10th 
day, to have suffered an accession of fever, seemingly caused by abdomi- 
nal irritation ; he complained much of headache ; the eyeswere injected; 
skin hot and dry ; tongue brown and crisp ; pulse 144; respiration 49; 
throbbing of the temporal arteries ; when undisturbed, raving and moan- 
ing, but answers rationally ; abdomen full and tense, tenderness in region 
of colon, with some tenesmus ; sleeplessness. He was given calomel, 
gr. iv. ext. hyosciami, gr. iii. followed by an oil draught ; a blister was 
applied to the abdomen ; cold to the head, and warmth to the feet. The 
medicine acted well, producing a number of dark-coloured motions, with 
some relief of the symptoms ; the sleeplessness, however, still continuing. 
On the 12th, raved considerably the previous night, with great restless- 
ness ; headache, with darting pain ; pulse 120 ; still answers rationally, 
but raves when left to himself; abdomen soft; he was again put on the 
use of the tartar emetic and opium mixture, to have one tablespoonful 
every hour for three doses, and then only every second hour. On the 
following day there was a considerable improvement; he had slept well, 
and perspired freely in the night ; no raving ; headache gone ; pulse 96 ; 
heat of skin less ; to continue his mixture. On the 14th day he was 
much better ; he wished for food. On the 15th day he suffered a relapse 
from his appetite having been imprudently indulged ; he was given an oil 
draught, and directed to resume his mixture when the bowels acted. He 
continued from this time to improve, the interval between the doses of his 
mixture was gradually lengthened ; and on the 17th day he was conva- 
lescent. 

" In this case, the good effects of this mixture were evidenced by 
perspiration and rest. This lad's mother and sister were just convalescent 
from spotted fever ; the former four weeks, the latter a fortnight. In the 
mother's case, I was not applied to till the 10th day ; it went on to the 
21st. There was not any organ particularly implicated ; she was treated 
with stimulants, carb : ammonias, porter, and blisters. In the daughter, 
the fever was very severe to the 11th day, when it terminated by profuse 
perspiration. She suffered principally from pain in her head and back, 
with intolerance of light, and was treated with mild aperients, followed 
by diaphoretics with hyoscyamus. In neither was sleeplessness distress- 
ingly remarkable. Another brother was seized with the same form of 
fever a few days after the subject of this case had taken ill ; he was on 
the 5th day transferred to Sir Patrick Dun's Hospital. 

" I experienced marked benefit from this form of prescription in a case 
of melancholia, occurring in a female aged 45, consequent on a severe 



150 CLINICAL MEDICINE. 

domestic affliction. The exhibition of it here, however, was followed 
by considerable debility, requiring stimulants. This effect I consider to 
have been, in some degree at least, attributable to the patient having for 
some days previous to its exhibition refused food, and possibly been suf- 
fered to remain too long under the sedative influence of this medicine 
without having been offered nourishment. 

u Hoping that you will excuse the hurried manner in which this case 
has been thrown together, 

" Believe me, my dear Sir, yours, 

"Henry Dwyer. 

" Camden-street, July 10, 1836." 

Case VI. — John Dillon, aged 15, a servant, admitted 5th June, 1835, 
several days ill. On the day of his admission he had headache, thirst, 
heat of skin, loss of appetite and rest ; his face was flushed and bloated ; 
eyes suffused, red, and prominent ; skin hot and dry ; he complained of 
slight epigastric tenderness and violent headache ; pulse were 120, full 
and bounding ; his whole body was covered with maculae ;> bowels regu- 
lar ; tongue brown, furred, and dry. Ordered, 

R. Aquae fontis, ^i. Liquoris Chloric!. Sodae gtt. x. M.fiat haustus quartishoris sumendus 
appl. hirudines, xii. pone aurem, et rej etatur applicatio si opus, 

7th. The leeches bled freely ; head appears to be relieved ; he raved 
a good deal during the night ; his pulse has fallen to 100, but still very 
full ; has a slight cough, and some bronchitis. Ordered to repeat the 
draught, and apply four leeches to the larynx. 

8th. Slept very little ; does not appear improved ; very irritable ; raved, 
and was rather violent during the night ; cough better ; tongue very 
brown and dry; bowels confined ; pulse 100 ; respiration rather hurried. 
Ordered to repeat the draught, and to have an emollient enema in the 
evening. 

9th. Epigastric tenderness much increased ; raved continually during 
the night ; slight subsultus ; eyes very red, wild and staring ; pulse 114, 
very full ; tongue dry and brown ; teeth covered with sordes. To repeat 
the draughts, and apply eight leeches to the epigastrium. 

10th. Appears better to-day ; epigastric tenderness much relieved by 
the leeching ; his strength is much prostrated ; wishes for more food ; 
pulse 100, and still full ; slept none. Ordered arrow T -root, and to repeat 
the draughts. 

11th. The fever is again much increaied ; raved violently during the 
night ; great prostration ; slept none ; subsultus very violent ; great 
thirst ; pulse 130; complains of a heaviness, but no pain in head : skin 
very hot and dry ; eruption undiminished. Ordered to repeat as before. 

12th. All the symptoms much aggravated, face flushed and red ; eyes 
suffused and ferrety ; teeth covered with sordes; lips parched and cracked ; 
tongue black and very dry; subsultus general and violent ; does not sleep 
either by night or day; exceedingly irritable; pulse 130 and jerking; 
pupils contracted ; he lies on his back with legs drawn up ; extremi- 
ties rather cold. He was ordered w T arm applications to his feet and the 
following prescription : — 

&. Tartar emetici, gr. ii. Misturee camphorse, ^viii. Tinctures opii, ^ii. M. Sumat coch- 
leare, i. amplum 2a q.q. hora. 



FEVER. 151 

13th. The nurse reported that after he had taken the mixture three 
times, he slept calmly for nine or ten hours, the first time for the last week. 
It operated largely after the second dose, the stools being thin and bilious. 
He has ceased to rave ; the suffusion has quite disappeared ; tongue is 
moist and cleaning. He slumbers continually, subsultus completely sub- 
dued ; answers questions rationally ; pulse has fallen to 98 and soft ; 
ordered to repeat the mixture. 

14th. Slept continually since last report ; general appearance much 
improved ; perspired profusely during the night. He was perfectly sen- 
sible from this day till the 17th. He continued to improve rapidly in 
strength and appearance. 17th, convalescent. 

Case VII. — Mr. S. , residing in College, was attacked with head- 
ache, on the 3d Feb. 1836, and fever commenced on that or the follow- 
ing day. He was judiciously treated by Mr. Barker, of Britain-street, 
until the 4th day of the fever, when an increase of headache and pain in 
or behind the ball of the right eye, induced him to call me in. A bleed- 
ing from the arm much relieved the pain, and he spent a tranquil night. 
He got calomel and James's powders in small doses. On the 5th no 
change. 6th day of fever, macula began to appear, and his state became 
more alarming. 7th day, maculae abundant, restlessness, debility, very 
frequent sighing, thirst, &c, with a sharp pulse, and return of headache. 
Leeches to head and nostrils were ordered ; the latter because of an evi- 
dent tendency to epistaxis. 8th. Sir Henry Marsh saw him along with 
us. 9th and 10th. Grain doses of Dover's powders added to his medi- 
cine four times in the night, but did not produce rest. 11th. Perfectly 
sleepless night and day ; ordered in the evening, one grain tartar emetic, 
4 ounces of camphor-mixture, and one scruple of laudanum ; 1 table- 
spoonful every second hour. 12th. Moisture on skin ; began to sleep 
after second dose, and slept several hours tranquilly ; is to-day quite free 
from muttering and raving, which had commenced on the 10th day, and 
increased on the 11th ; so that when left to himself he lay on his back 
constantly speaking, but not in a loud or boisterous manner, his eyes 
being all the time open ; when addressed, he answered quite rationally, 
but on our quitting the room began again immediately to ramble. This 
group of unpleasant symptoms having disappeared, we did not continue 
the medicine, but ordered palliatives and mild nourishment; in the even- 
ing it was judged right to apply a blister to the nape of the neck. 13th 
day, macula?, very abundant ; was quiet during the night, but did not 
sleep at all ; exhausted and nervous ; other symptoms moderate ; pulse 
104 ; tongue moist ; abdomen a little swollen and slightly tympanitic ; 
turpentine injections ; continued palliative diuretic draughts ; chicken- 
broth ; claret and water. At 5 p.m. I again saw him, and found him still 
quite sleepless, but without headache; bowels moved, but still slightly 
tympanitic. Fearing the continued exhaustion from want of rest, I now 
ordered a mixture consisting of one ounce of mucilage of g;um arabic, 
seven ounces of camphor-mixture, three grains of tartar emetic, and one 
drachm by measure of laudanum ; half an ounce every second hour until 
sleep comes on. At ten Sir Henry Marsh and Mr. Barker saw him ; he 
had slept an hour ; appeared drowsy, and did not complain of headache; 
two doses of the medicine had been given ; he remained awake until 
eleven, when another dose caused him to sleep until three ; at four ano- 
ther was given, after which he slept until eight, and awoke much refreshed, 



152 CLINICAL MEDICINE. 

and much improved in every respect ; his belly had not been moved, and 
was still slightly tympanitic, a symptom which yielded to the administra- 
tion of two drachms of castor oil exhibited in the form of an aromatic 
emulsion. In the evening he was ordered to take four drops of black 
drop, but this procured no sleep during the night. On the morning of 
the 15th day we found him somewhat exhausted from a sleepless night, 
but with much less fever and no headache ; pulse 94, soft ; for the first 
time we remarked subsultus ; a family idiosyncrasy rendering musk pe- 
culiarly disagreeable, or even intolerable, we ordered a draught containing 
two drops of black drop, and fifteen of Hoffman's liquor, every fourth 
hour. In the evening he had slept very little, so that I resolved again to 
recur to the antimonial opiate ; two spoonfuls of which produced sound 
refreshing sleep for several hours. In the morning he again got castor oil ; 
and on this, the 16th day, his pulse was only 70 ; but still, though the 
subsultus was diminished, a remnant of it could be perceived, so that he 
could not be pronounced out of all danger. 

The conclusion of this case is peculiarly instructive, and proves how 
insidious is the progress of fever, and how unsafe the condition of a patient 
whose brain and nervous system have received a violent shock, even al- 
though the immediate consequences of that shock have been averted by 
the employment of decided treatment. On the 16th day we have seen an 
abatement, or rather a disappearance of almost every symptom of the dis- 
ease, save and except a slight, a scarcely perceptible remnant of the sub- 
sultus. Great care was taken to prevent his being disturbed, and the 
strictest attention as to diet was enjoined ; indeed he was remarkably dis- 
inclined to taking food, and it was with great difficulty that we could get 
him to consume a sufficient quantity of mild farinaceous diet. On the night 
of the 16th day he slept tolerably. The 17th day was passed without any 
change; but he slept none that night. The 18th day he was perfectly free 
from fever; pulse 70; tongue moist ; bowels opened by medicine. That 
day he conversed too much to his friends about his removal to the coun- 
try, his future plans, &c. ; but nevertheless he slept several hours towards 
evening. This sleep was disturbed and chequered by dreams, and on 
aw T aking about eleven o'clock, he was wandering, and got eight drops of 
black drop, which procured no rest ; on the contrary he got several times 
out of bed, and spoke incoherently. The raving had all subsided at 
10 a.m. on the 19th day, when I was in hopes it was entirely owing to 
temporary excitement, and would not return ; an opinion rendered proba- 
ble by a total absence of all symptoms of general or local vascular excite- 
ment, of headache, &c. In this expectation, however, I was disappointed, 
for early in the afternoon he became incoherent ; raved more and more 
every hour ; complained of headache ; could not bear the light ; and when 
I saw him at seven, he was quite irrational; supposed himself to be travel- 
ling; and when questioned he seemed not to understand; his pulse had fallen 
below 60; was soft, irregular, and intermitted very frequently ; skin not hot; 
feet cold; features contracted ; tip of nose cold ; he had eaten stirabout in small 
quantity twice during the day, but in a voracious unnatural manner; his 
eyes were a little red, and every thing wore a most threatening aspect. 
What was now to be done? In directing his head to be shaved anew, 
and in applying blisters to his scalp and temples, I felt I was proceeding 
on sure grounds; but the indications for the internal treatment were less 
obvious. We had arrived at the 19th day, and he had gone through a 
debilitating fever, and had been submitted to a very active mode of treat- 



FEVKR. 153 

ment. Were we to leech the head ? were we to apply cold? and should 
we immediately endeavour to mercurialize the system by means of mer- 
curial preparations, given internally and applied externally? Such would 
have been the treatment a patient, under similar circumstances, would 
have undergone at the hands of any practitioner a very few years ago ; and 
I have no doubt that a treatment of this nature would have speedily brought 
matters to a fatal termination. The writings of Gooch, however, who 
pointed out the diagnosis and treatment of certain cases, usually confounded 
with inflammatory hydrocephalus, and the influence of the truth of Dr. 
Gooch's statement, as illustrated by several examples in our own practice, 
determined Sir Henry Marsh, Mr. Barker, and myself, to rely on the severe 
blistering locally, while internally, we ordered a draught consisting of two 
grains of carbonate of ammonia, twenty drops of Hoffman's liquor, and 
one ounce of camphor-mixture, to be taken every third hour. Warmth 
was applied to the feet, and he was supplied with warm whey. Shortly 
after our visit he fell asleep, slept with little interruption for about seven 
hours, and awoke perfectly rational; and at eight o'clock next morning, 
being the 20th day, we found him much better in every respect; the only 
vestige of this alarming attack that remained being some intermission in 
the pulse, which had become in other respects much more natural, and 
fuller. The bowels had not been opened; a circumstance I mention be- 
cause, no doubt, some would have ordered purgatives on such an emer- 
gency, a practice which the fallen, soft state of the belly did not seem to 
us to call for, and which our view of the nature of the case prevented us 
from proposing. We ordered farinaceous diet, and a repetition of the 
draughts, at longer intervals. In the evening of the 21st day the pulse 
had lost all remnant of irregularity or intermission, and the disturbance of 
the nervous system had entirely subsided: from that period his convales- 
cence commenced. 

One fact connected with the cases just related is very striking, viz. the 
small quantity of laudanum which, in most of them, was sufficient to induce 
sleep; a circumstance only to be accounted for by the presence of the tar- 
tar emetic, which no doubt exerts, when given in duly regulated doses, a 
powerfully tranquillizing effect on the nervous system. It is also deserv- 
ing of remark, that the medicine very seldom gives rise to any of the un- 
pleasant symptoms that so frequently arise when opium alone, or any of 
its preparations, are given with a view of producing sleep at an advanced 
period of fever. The addition of one ounce of mucilage, and one ounce 
of simple syrup to the mixture, seems to render it less iikely to disagree 
with the stomach. Towards the termination of fever, it not unfrequently 
happens that a sudden or gradual determination of blood to the head arises, 
and which requires a repetition of a modified system of antiphlogistic treat- 
ment, aided by blisters. This state, I have reason to believe, may be often 
prevented from occurring, by a timely attention to procuring sleep; for a 
patient in fever, who has passed several sleepless nights, is on the vers;e 
of cerebral congestion or inflammation, as is testified by headache, wan- 
dering, and the redness of the conjunctiva. Here it is that the treatment 
I recommend is so advantageous, when timely applied ; for if it be de- 
ferred until cerebral inflammation has set in, opium in any shape is worse 
than useless. 

I have notes of several other cases, equally strong, in favour of the 
utility of tartar emetic and opium in the advanced stage of fever, but think 



154 CLINICAL MEDICINE. 

it unnecessary to bring them forward, as the above seem sufficient for my 
present purpose. The particular state of the nervous system to which this 
combination of remedies is best adapted, may occur, along with other 
symptoms produced by functional or organic lesions of various organs, and 
which prevent it from producing the wished for beneficial result. Thus 
when the belly is tense and swollen, this remedy will generally fail ; but 
I think that I am warranted in asserting that in fevers, properly treated 
from the first, tympanitis may commence, but will never become consider- 
able; for, if the attention of the practitioner be applied to this symptom 
the moment it begins to show itself, he can in most cases succeed in arrest- 
ing its progress. I have likewise seen several cases of fever, where I ex- 
pected benefit from the tartar emetic and opium, and in which no good 
result followed the exhibition of these medicines; such failures must always 
occur with respect to every remedy we apply in disease, but they do not 
invalidate the evidence of facts, such as I have brought forward in proof 
of their frequent utility. In connection with this subject, I beg leave to 
draw the attention of practitioners to the occurrence of delirium traumati- 
sm in fevers, in consequence of the irritation produced by blisters, a spe- 
cies of delirium apt to be mistaken, especially in children, for the delirium 
ushering in hydrocephalus. It is unnecessary to do more than advert to 
this subject, as I have spoken of it at some length in the lectures before 
referred to. To conclude, it is right to remark, that the relative propor- 
tions of tartar emetic and laudanum in the mixture must be varied accord- 
ing to circumstances. 

When congestion of the brain is known to exist, or is feared, the tartar 
emetic must not fall short of four grains in the eight ounces, while the 
laudanum should not exceed half a drachm; but where nervous symptoms 
predominate, the laudanum may amount to one drachm, and the tartar 
emetic to two grains: no general rule, however, can be laid down, and 
the practitioner must in all cases watch the effects of this medicine, from, hour 
to hour, until he ascertains whether it agrees with the patient or not. 
Where a life is at stake, we must spare no pains, and must not reject a 
remedy because its powers render it an instrument of good or evil, accord- 
ing as it is administered carefully or otherwise. 

ARTICLE II. 

The following cases occurred since the publication of the last number of 
this Journal, and I hasten to publish them, for many reasons. In the first 
place they prove that tartar emetic, in considerable doses, may be admi- 
nistered with advantage at a period of fever in which it was usually 
thought to be inapplicable, and to an extent which even now I cannot 
but consider as remarkable. In my former communications upon the use 
of tartar emetic and opium, I had not pushed the former remedy with the 
boldness and decision I have since done, for my experience only gradually 
accustomed me to a method of proceeding contrary to preconceived 
opinions, and my views of the powers of the remedy only gradually en- 
larged as I became more confident of its safety. It is but right to add, 
and I do it with gratitude, that I received much assistance and encourage- 
ment from the views of Dr. Marryatt of Bristol, published in 1788, but of 
which I and the profession in Ireland, and I may add in England, were 
generally ignorant until they were noticed in the last April Number of the 
British and Foreign Medical Review. This notice of a work, of which I 



FEVER. 155 

had never before heard, and the testimony it contained that tartar emetic 
maybe exhibited in considerable doses, and with advantage, at advanced 
stages of malignant fever, led me to attach more importance to this re- 
medy alone, and uncombined with opium, and determined me to adopt a 
bolder line of practice in future, a determination which the event fully 
justified. 

Some there are who will take occasion to remark that t can have no 
claim to originality on this occasion. But all who have watched my 
practice in the hospital, nay, all who have taken the trouble of reading 
my lectures and successive publications on this subject, will at once ac- 
knowledge that I proceeded on this path of investigation with no other 
guide but an analogy derived from an observation of the effects of tartar 
emetic and opium in delirium tremens, a disease undescribed in the time 
of Marryatt. Every one the least conversant with the treatment of fever 
in private and in hospital practice in Dublin, London, and Edinburgh, 
will allow that no one during the present century ever taught or practised 
the exhibition of tartar emetic at the stage of typhus fever in which I have 
recommended it. Not a single hint at such a treatment is given in any 
of the numerous contributions on the treatment of typhus, which form the 
valuable work edited by Dr. Barker and Dr. Cheyne. Where is there 
even one allusion to this practice in Armstrong, Smith, Tweedie ? And 
what is said of it in Good, Thomas, Mackintosh, or in the Cyclopaedia of 
the Practice of Medicine? Where is it mentioned or inculcated in the 
Edinburgh Medical and Surgical Journal, or in Johnson's Medico-Chi- 
rurgical Review ? Nowhere ; although the treatment of fever is often 
the subject of anxious discussion. 

So far suffices with regard to the novelty of the matter, for it is useless 
to argue with persons so stupid as to confound the practice I recommend 
with the well-known and popular use of tartar emetic as an emetic or a 
diaphoretic in the commencement of febrFIe diseases generally. That I 
did not come upon this method sooner, I regret infinitely, for since its 
adoption, my practice in hospital and in private has been much more for- 
tunate than formerly. Nay, shortly before Mr. Cookson's illness, I lost 
several of my friends, relatives, and patients, who would in all probability 
have recovered if so treated ; and among the rest a gentleman, the very 
week before the first trial I made of the practice in Mr. Cookson's case. 
I mention this fact as the strongest and most convincing proof that I had 
never even thought of this method until Mr. Cookson's case occurred, for 
had I done so I would have surely been inexcusable in allowing my pa- 
tients to perish without even trying its effects. But it is time to proceed 
to the cases themselves. 

The first case occurred very lately in the Meath Hospital, where its 
progress was anxiously watched by many students and several practitioners, 
all of whom concurred in the opinion that the patient must have died had 
he been treated according to the plan usually followed under similar cir- 
cumstances. This patient was attended under my directions by Mr. Har- 
nett, who took the following notes of its progress, and visited the patient 
with unremitting attention both by day and by night. 

Joseph Taylor, aged twenty-one, a strong young man, of temperate 
habits, admitted into hospital on the 7th May, 1836. Ill seven days; 
sickness commenced with rigors, headache, pains in loins, &c. On ad- 
mission he complained of headache, tinnitus aurium ; face was flushed ; 



156 CLINICAL MEDICINE. 

eyes slightly suffused ; was constantly frowning ; skin hot and dry, slightly 
maculated ; abdomen full and soft ; bowels confined. 

Habeat Haustum Rhei. 

9th. Slept pretty well ; raved little ; ringing in ears continues; head- 
ache increased ; eruption of macula? much more copious ; slight cough ; 
some bronchitic rales over both lungs ; abdomen in every respect natural ; 
bowels regular ; pulse 100, distinctly dicrotous and sharp ; tongue brown, 
dry, rough, and furred ; had slight epistaxis three days ago. 

R. Pil. Hydrarg. gr. iii. Pulv. Tpecacuanhae gr. ss. M. Ft. pilula 4tis horis sumenda, 
applicentur Hirudines ii. naribus et repetatur applicatio hirudinum vesperi si opus. 

Tenth day of fever. Slept tolerably well ; bled copiously from nares ; 
pain in head diminished ; countenance still flushed and hot ; temperature 
of rest of body lower than natural ; feet very cold ; pulse 112, dicrotous 
and wiry ; tongue parched and furred, dark brown, great difficulty in pro- 
truding it. 

Stupes to feet, blisters to precordial region ; blisters to calves of legs 
in the course of the day. 

R. Mist. Camphorae ^i. Liquoris Hoffmanni gi. M. Ft. Haustus 4tis horis sumendus. 

Eleventh day. Became very violent yesterday evening; attempted to 
get out of bed frequently, but when spoken to by the nurse, he remained 
quiet for a short time ; w T as constantly raving and gnashing his teeth du- 
ring the night ; had no sleep ; a short time before visit this morning, had 
a fit of an epileptic character, which lasted about ten minutes, in which 
he worked violently, and foamed at the mouth ; at the hour of visit, nine 
in the morning, the countenance w T as flushed, anxious, and expressive of 
great ferocity; eyes wild and suffused ; pupils natural ; complains of dim- 
ness of vision ; eye-brows contracted ; breathing hurried ; is constantly 
tossing himself from one side of the bed to the other, and tearing the 
dressings off the blistered surface ; skin hot and dry ; abdomen soft ; no 
tympanitis ; bowels loose ; tongue parched and furred ; he is incessantly 
protruding and biting it, and gnashing his teeth ; pulse dicrotous, very 
quick, and somewhat hard, but small. 

R. Antimonii Tart, gr vi. Aquae Fontis^x. Mucilaginis Syrupi Papav. albi aa ^i. M. Ft. 
Mistura, sumat ^ss. omni semihora. 

Three o'clock, p.m. Has taken half the mixture, was nauseated by 
the second dose, but not since ; he still continues very violent ; fancies 
he has a bone in his mouth which he is constantly biting ; is in a copious 
perspiration since he commenced taking the medicine. 

Mr. Harnet ordered |i. of the mixture every half-hour. 

Six o'clock, a.m. Appears a little calmer ; has taken the whole of the 
medicine, no nausea produced ; has bitten his tongue and lip severely ; 
perspiration continues ; has passed a large quantity of urine in bed ; pulse 
soft and full. 

R. Antimonii Tart. gr. iii. Aquae Fontis Jvss. Syrupi Simplicisgss. M. Ft. Mistura cujus 
sumat ^ss. omni semihora. 

Eleven o'clock, p.m. Has taken all his medicine without being nau- 



FKVKR. |57 

seated ; countenance less flushed ; is constantly raving ; pulse 100, full 
arul soft. 

R. Antimonii Tart. gr. iv. Mist, camphorae 3 viii. Tinct opii. gi. M. Ft. raisturst rujus 
capiat £ss. omni semihora. 

12th. Continued raving through the night ; had no sleep ; appears 
much quieter this morning ; face less flushed ; eyes still wild and staring, 
but very slightly suffused ; brows contracted ; pupils natural ; sp< 
rationally ; pulse 80 and regular, has lost the dicrotous tone which it had 
yesterday ; bowels confined. 

Habeat enema emolliens, rept. mistura ; to have one pint of porter and chicken-broth. 

Three o'clock, p.m. Having taken the whole of the mixture, contain- 
ing tartar emetic and opium, the simple tart, emetic mixture was again 
prescribed ; after taking two doses of which he fell into a tranquil sleep, 
in which he is at present. 

Eight o'clock, p.m. Has slept continually all day, awakes occasionally, 
but falls into a deep sleep very soon again. 

Omittatur tinct. opii. 

13th. Slept soundly during the night ; appears calm and collected ; 
conversation quite rational ; maculae have disappeared ; pulse 84, soft and 
regular; omit medicine ; a glass of porter ; light nourishment. 

He has taken more than twenty grains of tartar emetic within thirty 
hours, and has been nauseated but once. 

There are some circumstances in this case which require to be con- 
sidered more at length. In the first place it is well to bear in mind that 
the patient was affected with genuine maculated fever, the true typhus, in 
the form many years present in Great Britain and in Paris ; for in the 
latter city this peculiar eruption, somewhat resembling measles in the 
crescentic shape of the blotches, is considered quite pathognomonic of 
typhus.* This is important, particularly with reference to the use of tartar 
emetic in such large quantities; again it is worthy of remark, that symp- 
toms of collapse, so alarming as to excite considerable apprehensions, and 
calling for the immediate application of blisters and the use of stimulants, 
occurred on the 10th day of the fever. It was immediately after this col- 
lapse that the violent cerebral excitement commenced, and certainly this 
previous collapse left an impression on my mind that no directly evacu- 
ating remedies could be borne ; that they would, at least, be attended by 
great danger of speedily reproducing a fatal degree of debility ; for this 
reason I did not repeat the application of leeches. The delirium in this 
patient was extremely violent, requiring the use of the strait waistcoat, 

* [This remark of Dr. Graves is certainly erroneous. The eruption of 
rose-coloured spots on the abdomen and thorax is, it is true, one of the 
pathognomonic symptoms of the typhoid fever of Paris, but at the same 
time it is very different from the abundant eruption of maculae resembling 
measles which occurs in true typhus fever. The latter covers the whole 
body, and is not confined to the abdomen, thorax, and occasionally the 
upper part of the thighs. — W. W. G.] 



158 CLINICAL MEDICINE. 

and the constant superintendence of the nurse ; the contortions of face, 
and the ferocity of his countenance, the constant biting of his tongue and 
lips, presented a frightful picture of excitement, which evidently could 
not be controlled except by the prompt and energetic use of powerful 
remedies. As the blistered surface on his chest seemed to add much to 
the state of excitement, for he was constantly tearing it, I did not think 
of applying blisters to the head, being persuaded that they might aggra- 
vate the evil, since in many they seem to act so as to produce a sort of 
delirium traumaticum. His pulse being frequent and sharp, together with 
the evident determination to the brain, seemed to indicate the exhibition 
of tartar emetic, nor was there any thing in the state of the intestinal canal 
to forbid its being given in frequently repeated doses. The result more 
than realised our expectations, for during its use the delirium gradually 
abated, and the pulse, becoming much less frequent, changed its character 
from a short and small, to a full soft stroke. This prepared the way for 
the safe trial of opium, which was not commenced until he had taken 
twelve grains of the tartar emetic. The opium was afterwards laid aside, 
and the tartar emetic alone completed the cure ; but it may be doubted 
whether alone it would not have induced sleep. 

I have made these remarks for the purpose of rectifying an erroneous 
impression, which I fear has gone abroad concerning the use of tartar 
emetic and opium in the delirium of fever, and to prevent, as far as I can, 
the exhibition of opium, except when certain precautions have been taken 
by the practitioner to remove or diminish cerebral congestion by means 
of proper evacuations or tartar emetic. No man can justly be held re- 
sponsible for the abuse by others of remedies he recommends ; but since 
the publication of my paper, in the last number of the Dublin Journal of 
Medicine, I have had lamentable proofs that I have been misunderstood ; 
and lately was called to see a gentleman in the vicinity of Dublin, who, 
the practitioner in attendance said, had been treated according to my 
method, whereas the patient was killed, according to his own, by opium 
injudiciously given during delirium with evident cerebral congestion. 

It has been asserted, that after all, this case was not so dangerous, nor 
its recovery very remarkable. For a full refutation of so groundless an 
opinion, I refer with confidence to the written history of the case itself, a 
history which is far from laying before the reader an adequate picture of 
the deplorable state of the patient at the time that my treatment was about 
to be commenced, but which, nevertheless, is still faithful enough to con- 
vince every one at all acquainted with the symptoms and progress of 
fever, that the case was almost hopeless. What! is it possible that any 
one can be found, who has witnessed fifty cases of bad fever, and who is 
bold enough to say, that because the patient is young and was previously 
healthy, he could not be considered in imminent danger, when on the 
tenth day of spotted fever, a state of collapse requiring blisters and stimu- 
lants is followed on the eleventh day by delirium of the most violent de- 
scription, rendering it necessary to tie the patient dow r n in bed, and 
accompanied by a fit of convulsions of frightful violence, lasting more than 
ten minutes, and resembling an epileptic seizure ? 

This last symptom alone is more than enough to denote extreme dan- 
ger. For the truth of this assertion, I appeal to my own experience, to 
the experience of every practical man, and to the writings of every author 
who has written on fever. Hippocrates has four aphorisms, all testifying 



FEVER. 159 

the danger of convulsions in fever; and in his book of prognostics, he 
says, that various causes may, in fever, produce convulsions in children 
under seven years of age, without great danger to life ; but he adds with 
great emphasis, in adults, convulsions never take place unless u n rwfMfxwn 
7r£oa-yiv>nxi vuv io-^v^ottatuv <re **< £a«<0-<r»r." It is scarcely possible to describe 
the danger of any thing in stronger terms than these. 

Those who assert that the possession of previous good health, or of a 
robust frame, renders violent fevers less dangerous, know little of the 
matter. The strongest and most powerful men I ever knew, were Dr. 
Clarke, jun., and Dr. Duigenan ; they both died before the end of the 
third day! 

I cannot pass over in silence the remark, that my cases only prove how 
much the powers of nature are able to bear, an observation involving the 
insinuation, that I was very culpable in giving such an example to others, 
and in countenancing the exhibition of strong medicines, such as tartar 
emetic in unwarrantably large doses. Now with all due deference, I may 
be permitted to observe, that in acute diseases threatening immediate 
danger to life, we gain little by waiting for Nature's assistance. Power- 
ful remedies must be employed ; but mark, if they are employed judi- 
ciously, their powers are only exerted in controlling (he disease ; this hap- 
pened in all the cases I have related, none of the patients were injured in 
any way ; in truth, the physician who orders one-fourth or one-half grain of 
tartar emetic to be given repeatedly until the disease yields, and who 
diminishes the frequency of the dose and the quantity of the medicine, in 
proportion to the diminution of the symptoms, to curb which was his object, 
that physician cannot be justly accused of giving heroically large doses of 
the medicine in question. To give it in smaller and less frequently repeated 
doses than are found sufficient to make an impression on the symptoms, 
would be mere trifling. The doses of medicines must be pronounced to 
be large or small, not according to their weight or measure, but according 
to their effects, and when confessedly moderate doses are frequently given, 
and the effects of each carefully watched, surely caution herself can re- 
quire no more. The same remark applies to my directions concerning 
opium. 

Case II. — The next case I have peculiar satisfaction in laying before 
the readers of this Journal, inasmuch as its progress and treatment were 
witnessed by the Surgeon-General, Sir P. Crampton, who was struck by 
the benefit resulting from a mode of practice he had never before seen 
applied, and that, under circumstances which he considered as indicative 
of the greatest danger. Dr. Campbell too had an opportunity of witness- 
ing for the first time this mode of treatment, and he since assured his 
class, that when I recommended it, he had scarcely a hope that our pa- 
tient's life could be saved. 

Mr. C, residing in Fitzwilliam-square, a surgeon, formerly an appren- 
tice of the Surgeon-General, a young man of a powerfully athletic make, 
was attacked with the rigor of fever on Monday, 9th May, 1836. He 
was attended from the commencement by Dr. Campbell, and had a copious 
eruption of measles-like macula?, on the sixth day of the fever, when I 
first saw him. No unusual symptom occurred on the seventh day, and 
the headache, of which he complained much at the commencement, had 
disappeared in consequence of the application of a few leeches. On the 
morning of the eighth day, we observed that every now and then he 



160 CLINICAL MEDICINE. 

respired irregularly, as if repeatedly and gently sighing, a variety of 
respiration often indicating a disturbance of the nervous system, and which 
I have repeatedly observed as a precursor of cerebral excitement, and to 
which, consequently, I have been in the habit of drawing the attention of 
my clinical pupils, under the name of cerebral respiration. On the after- 
noon of the eighth day, we had the benefit of the Surgeon-General's ad- 
vice, who thought his case a very bad one indeed, for his pulse was almost 
140 in a minute, and remarkably shabby, while he lay on his back thickly 
covered with maculae ; and we found that a rapid tumefaction of the ab- 
domen had commenced within a few hours ; a very bad symptom, inas- 
much as the belly had been in the morning quite soft and fallen, and there 
was no cause to account for the sudden development of tympanitis, unless 
w T e supposed it, as it too frequently is, a harbinger of dissolution at no 
very distant period. His tongue was parched, and he complained of 
thirst. The usual treatment by means of chloride of soda was determined 
on, in consultation ; after which the Surgeon-General expressed to the 
gentleman's friends, the fears he entertained for the result. Scarcely had 
the Surgeon-General gone out of the house, and just as Dr. Campbell and 
T were preparing to leave it, a sudden change took place in our patient, 
who jumped out of bed, and nearly succeeded in throwing himself out of 
a garret-window. We found him violently delirious ; but this state did 
not last more than a few minutes, when it subsided into a delirium of a 
comparatively gentler description. He refused, however, to return to 
bed, and we were obliged to allow him to walk about in his shirt, sup- 
ported, for he was feeble, by two attendants ; his eyes became at times 
very prominent and ferocious; now and then he threatened all those about 
him, in a loud and terrifying tone of voice, and he seemed every moment 
on the borders of frantic madness. Nothing could induce him to go to 
bed, or allow even a blanket to be thrown over his cold and naked ex- 
tremities. Thus, seated on his chair he presented a frightful picture, 
while his pulse became so quick, that it could scarcely be counted, and 
was, at the same time, exceedingly weak. What was to be done ? The 
state of his circulation did not admit our endeavouring to control the cere- 
bral excitement by anteriotomy or even leeches, and the last remark the 
Surgeon-General made was, that a very few leeches would kill him ; 
blisters would be too slow in their action, and might even aggravate the 
disease ; cold effusion seemed inadmissible. In short it seemed that our 
patient was beyond the reach of all our resources ; as to tartar emetic, I 
felt at first unwilling to order it on my own responsibility, in a case appa- 
rently so desperate, and after Sir P. Crampton had left the house ; in fact, 
neither Dr. Campbell nor I thought it probable that our patient would 
survive twelve hours ; yet as I saw no possible means of saving him but 
the tartar-emetic treatment, and determined at all risks to make a strenu- 
ous effort, I did not think myself justified in any longer hesitating about 
the matter, and ordered a mixture containing one ounce of syrup of white 
poppies, one of mucilage, and six of water, with eight grains of tartar 
emetic. Of this solution he was to get half an ounce every half-hour, 
until a manifest impression on the cerebral excitement was produced. 

The medicine was administered by Mr. Ferguson, of Kildare-street, so 
well known as a skilful and excellent apothecary, and who told me after- 
wards that he was quite surprised at the treatment adopted, and was sure 
that neither it nor any other could save Mr. C.'s life. The first six doses 



KKVER. 161 

seemed to sicken him a little, but he did not vomit until after the seventh 
dose ; the eighth also produced very copious vomiting of mucous and 
bilious fluid. After the second vomiting he was prevailed on to go to 
bed, and was evidently more tranquil, but from having remained up un- 
covered for so many hours, much trouble was necessary before warm 
applications succeeded in restoring the natural temperature of his limbs 
and skin generally. 

At 10p.m. we saw him again, and finding that the medicine had produced 
so powerful an effect, we ordered it to he repeated only every second hour. 

May 18th. — Ninth day of fever ; 8 a.m. Has taken five doses since 
last visit ; stomach quiet since the eighth dose. He slept several hours 
quietly in the beginning of the night [he had not slept for several night- 
before), but seems more excited now ; he threatens some of bis attendants, 
and appears likely to be unruly. It was therefore judged right to repeat 
the medicine oftener, i. e., every hour and a half. 

1 p.m. Has taken eight grains of tartar emetic since six o'clock yester- 
day evening. A solution of the same strength in plain water was now 
directed to be given in the dose of half an ounce every fourth hour. He 
slept a good deal during the day, and the medicine operated on the bow- 
els, bringing down very large fluid stools, consisting of a great quantity 
of healthy yellow fecal matter. This effect is often produced by the tar- 
tar emetic in the advanced stages of fever, and is always a good sign. 
Although he was evidently more tranquil than before, it was thought 
advisable still to keep two strong steady men constantly in the room, 
ready to assist the nurse in case of emergency. He still raved occasion- 
ally, and would not allow certain persons, me among the rest, to approach 
him, having conceived a strong aversion for us. 

At 7 p.m., we found that the fever was again rising, and that the cere- 
bral excitement was on the increase; we therefore again had recourse to 
half-hour doses, until the excitement yielded ; after which it was given 
only every second hour. 

May 19th. — Tenth day of fever; 10 a.m. He took six doses during 
the night. He got out of bed and eluded the vigilance of his attendants 
at a very early hour in the morning, but walked peaceably about the 
house, and when asked returned quietly to bed. He slept well after- 
wards. As so much had been gained, we thought it unnecessary to per- 
severe in the use of the tartar emetic ; it was discontinued. He took in 
all twelve grains ; it diminished the frequency of the pulse notably ; and 
what was very striking during the forty-eight hours we employed it, the 
pulse not only became slower, but much softer and much fuller; the skin 
became softer and moist ; the belly was fallen and soft ; and the maculae 
much diminished. His fever, notwithstanding, still continued ; he spoke 
incoherently at times, but never again got out of bed. 

On the fourteenth day an evident abatement of general fever com- 
menced ; the pulse fell, and the respiration, which, when he w T as at the 
worst, had been about fifty in a minute, fell to twenty-five. This im- 
provement continued progressive, and on the seventeenth day precisely, 
all fever left him ; his pulse being then 60. 

The after-treatment consisted merely in giving a mild aperient every 
second day, until convalescence commenced. After the use of the tartar 
emetic had cured the cerebral excitement, he slept almost continually until 
the termination of the fever. 
12 



162 CLINICAL MEDICINE. 

Case III. — Mr. M., a gentleman of sedentary habits, full and corpu- 
lent, 40 years of age, was lately attacked with violent symptoms of fever. 
He was very actively and judiciously treated by Dr. Ireland from the 
commencement. The measles-like eruption appeared about the fifth day. 
He had been copiously bled from the arm twice, and leeches were repeat- 
edly applied to the forehead for the purpose of relieving pain in the head. 
He was likewise very freely purged. About the time the eruption ap- 
peared, his restlessness and debility increased, and he scarcely slept at 
night. In the course of a few days his state had become very alarming, 
and I saw him in consultation with Dr. Ireland, on the ninth day of his 
fever. 

We found that he had raved constantly during the preceding night, and 
was bathed in an exhausting perspiration, while the pulse rose to about 
130 ; his respiration was very frequent, and his face wore an evident 
expression of excitement, not of a violent, but of a very restless character. 
His tongue was parched, and his body thickly covered with macula. In 
short, notwithstanding the active measures of depletion, general and local, 
applied in the beginning of the disease, it was evident that Gerebral excite- 
ment had come on, and that too at a period of fever when debility forms 
a formidable obstacle to the further use of direct evacuants. His exceed- 
ingly gross habit of body, and prominent abdomen, were concomitants of 
the worst omen, for it is well known that very fat people seldom recover 
from typhus of a bad character. In this state of things tartar emetic was 
given to about the extent of three grains in the twenty-four hours ; it was 
continued forty-eight hours, or until a satisfactory calm of the nervous 
system had been produced. Besides diminishing the delirium and indu- 
cing sleep, the remedy here brought away numerous and copious bilious 
stools, and diminished notably the frequency of the pulse and of the respi- 
ration. It is worthy of remark also, that in proportion as he came under 
the influence of the tartar emetic, the useless and profuse perspiration 
began to abate, and after some hours ceased. 

This gentleman's life was evidently saved by the treatment, for though 
his fever continued many days after, yet he never was in danger except 
from hiccup, which came on about the thirteenth day, and tormented him 
day and night. Claret, iced, seemed to have more power in relieving this 
symptom than any other expedient resorted to. His fever terminated 
about the nineteenth day. 

Doctor Ireland, who has had the most extensive experience in fever, 
testified the pleasure he felt at witnessing the good effects of a mode of 
cure to him quite new, and applied in a case he thought almost desperate. 

Case IV. — The following occurred during the time these remarks were 
in the press, and presents so striking and convincing an illustration of 
the efficacy of my treatment, that I have thought it right to communicate 
it to the profession. The progress of this case was witnessed by several 
practitioners, who all declared, and I myself concurred in this opinion, 
that nothing could save the patient's life. His recovery was, without 
exaggeration, a matter of astonishment to us all ; while at the same time 
it was so evidently the effect of the remedies employed, that many who 
had been wavering in their minds as to the utility of tartar emetic exhi- 
bited in the advanced stages of spotted fever, could no longer refuse their 
assent, and unhesitatingly declared their conviction that by no other plan 
of treatment could a favourable issue have been brought about. The 



FEVER. 163 

patient was most diligently watched by Mr. Rooney, an attentive pupil, 
who visited him many times during the day and night, and reported to 
me the effect of the medicines. 

Edward Meylagh, a stout, muscular peasant, aged 25, was attacked 
about the 23d May, 1836, with the usual symptoms of commencing 
typhus. He was admitted into the Meath Hospital on the 1st of June, 
after the usual hour of visiting the wards. It whs ascertained that he had 
been repeatedly and violently purged since the commencement of his 
illness by pills and aperient mixtures. I saw him at 9 a.m. on the 2d of 
June: he had passed a most restless night, muttering incessantly, and 
becoming at times so unmanageable, that it was necessary to put on the 
strait waistcoat. Now he is obstinately silent, will not answer questions, 
or put out his tongue when desired. His countenance is at once morose 
and haggard, and at times assumes a suspicious, ferocious aspect ; eyes 
glazed, and slightly suffused ; general surface of skin rather dry and hot, 
but his extremities are cold and livid ; pulse 132, small and compressed ; 
respirations 42, irregular ; abdomen neither swollen nor tender ; he passes 
urine and feces in bed ; his tongue is dry, and dark-brown in centre, 
moist and red towards the edges. The whole surface of his body is 
covered with maculae. Immediate attention was paid to restore the 
warmth of the extremities, and I directed him to get every hour half an 
ounce of mixture, consisting of eight ounces of water, four grains of tartar 
emetic, and two scruples of laudanum. 

1 p.m. At mid-day he began to gnash his teeth, knit his brows, screw 
his lips, and spit at every person that approached his bed. The expres- 
sion of the face was rendered worse by the rapid motions of the eyeballs 
and a frequent squinting. In fact he became so ungovernable that the 
restraint of a strait waistcoat was no longer sufficient, and his legs and 
thighs were tied down to the bed. His carotids pulsated violently, and 
he alternately laughed and screamed aloud. Pulse 132, still small and 
wiry. As no perceptible action had been produced by the medicine, it 
was ordered in double doses. 

6 p.m. Countenance much improved ; less morose ; he continues, how- 
ever, to speak unconnectedly, but jocularly ; is in a copious warm perspi- 
ration : pulse 120, soft and compressible; respirations 36, regular. To 
continue the double doses. 

9 p.m. Has been in a composed tranquil sleep since half past six 
o'clock ; perspiration continues ; has passed a large quantity of urine ; 
extremities are now naturally warm and moist ; the pulsation of the 
carotids has subsided. He has taken four grains and a half of tartar 
emetic since morning, and twenty-three drops of laudanum. The medi- 
cine was now directed not to be given at regular intervals as before, but 
according as the symptoms seemed to require it ; it had neither nauseated 
nor purged him. 

3d June. He has slept tolerably during the night, and got three 
doses of the bottle.' About five in the morning he became somewhat 
restless, when a double dose was immediately administered, after which 
he slept composedly until nine o'clock, the hour of visit. His tongue 
is red, dry, and parched, fissured towards the tip ; his thirst is increased, 
and he drinks very freely of cold water ; skin moist and warm ; pulse 
96, dicrotous ; respirations 30, regular ; he seems inclined to sleep. His 
ideas are somewhat confused, although he answers rationally ; bowels 



164 CLINICAL MEDICINE. 

confined ; abdomen a little tumid and slightly tympanitic. Has taken 
two grains and a half of tartar emetic and ten drops of laudanum since 
yesterday evening. I now thought it unnecessary to persevere any longer 
in the use of this mixture, and directed my attention to the state of the 
bowels, which soon yielded to emollient lavements. The alvine evacua- 
tions so procured were very copious, and were followed by immediate 
subsidence of the belly, and evident amelioration of the symptoms. He 
continued to sleep quietly during the day ; at six in the evening his pulse 
was 90, soft and natural ; respirations 30 ; skin warm and perspiring ; 
maculae have nearly disappeared. 

7th June. Much natural sleep ; pulse 65, soft, of good strength, and 
without any of the dicrotous character ; intellectual faculties rapidly 
improving ; now passes urine and feces voluntarily ; abdomen soft and 
fallen ; tongue cleaning, and nearly moist. In fact, convalescence has 
almost commenced. 

Case V. — A gentleman about 20 years of age, was attacked with 
measles of an irregular form. The eruption did not come out favourably ; 
and notwithstanding he was treated from the beginning by Dr. O'Brien, 
so well known as an excellent writer on the subject of fever, his state 
became daily worse, and Dr. O'Brien pronounced his case hopeless when 
he sent for me on the sixth day. 

It must be borne in mind that Dr. O'Brien has been Physician to the 
Cork-street Fever Hospital for thirty years. The combination of symptoms 
which caused him to form this unfavourable opinion, were an exceedingly 
rapid, shabby pulse, violent delirium, total sleeplessness, and an evident 
sinking of the vital powers, manifested by coldness of the skin, &c. &c. 
As he was young, and the disease recent, we ventured to draw a little 
blood from the arm, but he fainted before many ounces could be obtained ; 
we leeched his forehead without any perceptible effect. On the morrow 
he was worse ; I then proposed the exhibition of small doses of tartar 
emetic, in frequently repeated doses. He took two grains in the course 
of ten hours ; was nauseated or vomited by almost every dose ; became 
more tranquil ; finally fell asleep, and in twenty-four hours was out 
of danger. 

Dr. O'Brien expressed to me in the strongest terms his gratification 
and surprise at the striking and beneficial application of a medicine he 
had never before seen given in like circumstances. 

Another case of spotted fever, to which I was called by Mr. M'Nalty 
of Britain-street, afforded an equally favourable result within this last 
week ; as did also a very dangerous case of the same disease, which I 
treated along with Mr. Mulock. 

I have thus fully laid before the public the result of my experience on 
this subject, convinced that I have not deviated in the slightest degree 
from the strict and naked truth in any of the preceding details. I have 
not in a single instance related what was not witnessed by other medical 
men of judgment, well known to the profession. If my treatment be not 
useful, it has singularly deceived me in curing my patients. If it be not 
new, it is strange that so many others in Dublin, that the whole body of 
practitioners should have been fully as ignorant of it as I was myself. 

To conclude, I must observe that I by no means wish to recommend 
tartar emetic as a specific in fever. I only use it in the complication 
above described. In fever the physician must use an almost endless 



FEVER. 165 

variety of treatment according to the circumstances of the individual case 
before him ; and he only will be successful who watches narrowly the 
progress of the cases intrusted to his care, and applies the appropriate 
remedies at the proper moment. Bleeding, leeches, purgatives, mercu- 
rials, antimonials, absorbents, acids, stimulants, tonics, blisters, chloride 
of soda, may each be necessary in the treatment of different cases at dif- 
ferent stages of their progress, or of different types. To conclude, the 
treatment of fever will be always difficult — always complex, but it ought 
to be successful. 

Tartar Emetic and Opium in the Delirium of Fever. — I have continued 
to derive advantage from this treatment, as described in the two last num- 
bers of the Journal, and have had the satisfaction of receiving most val- 
uable testimony concerning its efficacy from various members of the pro- 
fession, among the rest from Dr. Prichard, of Bristol, a physician distin- 
guished by extensive learning and practical knowledge. The annexed 
letter from Dr. Green, of Youghal, was not intended for publication, but 
it is perhaps on that very account more valuable. I have taken the lib- 
erty of printing it, because it corroborates the views I had advanced on 
a subject, which our readers will at once perceive derives a new interest 
from the truly instructive paper by Dr. Kennedy on the use of tartar emetic 
in the diseases of parturient women. 

"Yocghal, 26th Juxk, 1836. 

"Dear Sir — In reply to your letter of 21st, I have to regret that my 
having to remove to, and fit up a new residence, together with other mat- 
ters, so pressed upon my time during the late epidemic, that I did not 
take any notes of cases. I could not hazard a conjecture as to the modus 
operandi of the remedy you mention, but exhibited it in various forms and 
stages of the fever, and always with advantage. The first case upon 
which I tried it, was that of a soldier in the military hospital (of which I 
had charge in the absence of the surgeon), who was reported to be dying ; 
had been fourteen days in fever, lying prostrate with muttering delirium, 
extensive bed-sores, evacuations involuntary, total sleeplessness and hic- 
cup. In this case it acted like a charm, the third dose producing quiet, 
cessation of the hiccup and muttering. I then directed an additional 
grain of the tartrate to his mixture, and to have it taken every hour ; 
after the first dose of this he fell into a sound sleep, which lasted for seven 
hours, when he awoke, and from that moment steadily recovered. In 
another case where there was acute bronchitis, I employed it in con- 
junction with local depletion, with a similar result. It appeared to me, 
after various trials, that this medicine served not only to allay inordinate 
nervous excitement, but to equalize the circulation in such a manner as to 
obviate the mischief that might otherwise result from local determinations. 
On this latter supposition I chiefly tried it, and in every case hitherto 
(about seventeen) with decided advantage. All of the fever cases alluded 
to were maculated: in one the subject was a young lady of robust con- 
stitution, six months pregnant ; the excitement here ran very high, the 
delirium violent and heat intense. On the ninth day she had been more 
than forty-eight hours without sleep, when I commenced the use of the 
mixture in question ; it was continued, with various intervals, until the 
eleventh day, when the delirium, &c. had completely subsided, and rapid 
recovery took place. It is strange that in none of those cases did it affect 



166 CLINICAL MEDICINE. 

the stomach. I found advantage occasionally in altering the proportions 
of the mixture, and giving it hourly when the excitement ran high. The 
fever here is now on the decline, and of much milder character. I regret 
very much it is not in my power to afford you more information on the 
subject at present, but hope at some future day I may be able to furnish 
you with materials bearing on the point in question. 

" Yours faithfully, 

«R. GREEN." 



LECTURE XV. 

Wine in Fever. 

I cannot conclude the remarks I have to make on different points con- 
nected with the treatment of fever, without directing your attention, in 
an especial manner, to the phenomena of the heart's action as an index for 
the administration of wine. In the Fifteenth Volume of the Dublin Medi- 
cal Journal you will find a paper on this subject from the pen of my dis- 
tinguished colleague Dr. Stokes. From numerous observations he con- 
cludes that certain phenomena, which I shall presently detail, indicate a 
softened state of the heart, and that as soon as these phenomena present 
themselves, we should resort to stimulation by wine, &c. Dr. Stokes is 
of opinion that the pulse is a fallacious guide in fever, and that our atten- 
tion should always be directed to the impulse and sounds of the heart for 
guidance either for the administration or withholding of stimulants, and 
he then details the peculiar characters by which this weakened condition 
may be recognised. I shall now read out from Dr. Stokes's paper the 
leading doctrines contained in it : 

" We may thus arrange the cardiac phenomena obtained in our typhus 
fever : — 

" 1. Impulse and sounds remaining unaltered ; the action of the heart 
corresponding with that of the pulse. 

" 2. Vigorous impulse, with distinct and proportionate sounds, with 
absence of pulse for many days. 

u 3. Diminution of both sounds of the heart, with absence or great 
diminution of the impulse (foetal character). 

" 4. Diminution of the first sound, with cessation or great feebleness of 
the impulse. 

" 5. Complete extinction of the first sound, the second remaining 
clear. 

" 6. Predominance of the first sound, the second being extremely 
feeble. 

u In the great majority of cases, however, the following were 

the phenomena observed : — 

" 1. Diminished impulse. 

" 2. Diminished first sound, particularly of the left cavities. 

" With respect to the impulse we arrived at some unexpected results. 
Tn most cases, considered through the whole progress, the diminution and 
return of the first sound were accompanied with the diminution and return 
of the impulse. So far the phenomena were what we might expect. But 



FEVER. 167 

in some instances, at particular periods of the case, this accordance between 
the impulse and sound did not exist. In one case, the sounds became 
distinct before the impulse returned. In another the impulse became dis- 
tinct on the eleventh day, while the second sound greatly predominated. 
In a third case, we found that on the eighth day the sounds were not in 
proportion to the impulse ; and on the tenth, the impulse continued, but 
the first sound was totally absent. On the next day no impulse could be 
felt, yet the first sound was feebly audible. In the fourth case, the im- 
pulse on the twelfth day was less perceptible than on the day previous, 
but the first sound had more strength." 

Dr. Stokes adds, " It is difficult, or impossible, in the present stage of the 
inquiry, to offer any satisfactory explanation of these apparent anomalies ; 
but it seems certain, that under the influence of the typhoid condition, 
the heart may have sufficient force to give an impulse with little or no 
sound, on the one hand ; and on the other, its contractions may be ac- 
companied by a sound, although the impulse be absent. Whether we 
are to explain these facts by referring to particular states of innervation 
of the heart, or to organic alteration in the muscular fibres or their con- 
necting cellular membrane, is still to be determined." 

Farther on Dr. Stokes says, " That the cause of the want of impulse, 
and feebleness or cessation of the first sound, is a softening of the heart, 
I have no doubt. The evidence in favour of this opinion may be 
stated : — 

" I. That softening of the heart exists in typhus fever as a local dis- 
ease, and without any analogous condition of the muscles of voluntary 
life. 

" II. That in our dissections in the last epidemic, we met with this 
softening of the heart in cases which during life had presented the pheno- 
mena in question. 

" III. That the physical signs indicate a debility of the left ventricle 
principally, and it is this portion of the organ which is most often altered 
in consistence. 

41 IV. Laennec has stated, that in proportion to the severity of the 
putrescent phenomena, is the liability to softening of the heart. And 
the same observation is found to be true of the physical signs now de- 
scribed. 

" The average period when these phenomena appear is about the 6th 
day, and they cease about the 14th day." 

Dr. Stokes considers it highly probable that this softened state of the 
heart depends on an infiltration through its muscular structure, of a pecu- 
liar secretion, identical with, or closely resembling that mentioned by Dr. 
Staberoh, as occurring on the surface of the intestinal mucous membrane 
in cases of follicular ulceration. 

" This occurring in the heart seems to impair its functions to a great 
degree ; but the rapid restoration of the heart to health points out that the 
disease has not materially impaired its organic condition." 

" Finally," says Dr. S., " I would draw the particular attention of my 
readers to the fact, that in the great majority of these cases, the use of 
wine was followed by the happiest effects. I may safely refer to the cases 
in proof of this proposition, and I believe that in the diminished impulse, 
and in the feebleness or extinction of the first sound, we have a new, direct, 
, and important indication for the use of wine in typhus fever." 



168 CLINICAL MEDICINE. 

I will now read out the conclusions at which Dr. Stokes has arrived : — 

14 1. That the condition of the heart in typhus fever must be determined 
by the application of the hand and stethoscope, the pulse being an uncer- 
tain guide. 

" II. That a diminished impulse, ora complete absence of impulse, occurs 
in certain cases of typhus fever. 

" III. That in such cases we may observe a diminished first sound, or 
even an absence of the first sound. 

"IV. That both these characters may exist with a distinct pulse, 

" V. That though in most cases the diminution of the impulse and first 
sound co-exists, yet that impulse may exist without corresponding first 
sound, and conversely that the first sound may be heard although unac- 
companied by impulse. 

" VI. That these phenomena are most evident as connected with the 
left side of the heart. 

" VII. That when the impulse or first sound are lessened or lost, the 
return to the healthy character is observed first over the right cavities. 

" VIII. That in some cases both sounds are equally diminished. 

" IX. That in a few cases the first sound preponderates. 

" X. That these phenomena indicate a debilitated state of the heart. 

" XI. That they may occur at an early period of the disease, and thus 
enable us accordingly to anticipate the symptoms of general debility. 

" XII. That the existence of these phenomena, in a case of maculated 
adynamic fever, may be considered as pointingout a softened state of the 
heart. 

" XIII. That this softening of the heart seems to be one of the secondary 
local lesions of typhus. 

u XIV. That the diminution or cessation of impulse, the proportionate 
diminution of both sounds, or the preponderance of the second sound, are 
direct and nearly certain indications for the use of wine in fever." 

Though these doctrines are entirely new r , and may appear to some 
rather fanciful, yet for their general accuracy I can vouch. I cannot 
agree, however, with Dr. Stokes, in attributing the phenomena of a debi- 
litated heart to a softening of that organ, much less to the interstitial infil- 
tration of a peculiar secretion, analogous to that which Staberoh states he 
has observed on the mucous surface of the intestines in dothinenterite. 
On the contrary, I consider the heart, in typhus fever, to be affected with 
debility from the same cause which induces a debility of the voluntary 
muscles, and of the bladder and sphincter ani — that cause is a general 
prostration of nervous energy. That Dr. Stokes has seen the heart soft- 
ened in the examination of subjects that had been affected with typhus 
fever, I have no doubt ; but I would impute this condition to the effect 
of putrescence, a process which it is well known sets in with great 
rapidity in cases where death has been caused by any malignant disease. 
It seems difficult to conceive how the heart could contract in a case where 
" the right cavities were softer than natural, admitting the fingers through 
their walls without much resistance ; and in which, in the muscular 
structure of the left cavities, this change was much more remarkable, the 
weight of the finger being almost sufficient to penetrate its walls, they 
were so exceedingly softened : it was very easily torn, and the edges thus 
separated had no longer the moistened appearance, but seemed as if quite 



FEVER. 169 

dry. The septum cordis was equally softened ; there was some dark 
fluid blood in the right cavities." 

But the fact cannot be denied, that in many cases of typhus the heart 
becomes weak, that this weakness is manifested by a decrease in the 
strength of its impulse, or in the intensity of its sounds, or a change in 
their relative loudness and duration — and though I have never witnessed 
these changes without accompanying debility of the entire muscular 
system, and other evidences of prostration, yet I fully agree with Dr. 
Stokes, *' that in the diminished imnulse, and in the feebleness or extinction 
of the first sound, we have a new, direct, and important indication for the 
use oj wine in typhus fever," and one from which the junior practitioner 
in particular will derive the greatest assistance. 

But I also agree with Dr. Bell, the distinguished American Editor of 
Dr. Stokes's Lectures, that " important as is the guide thus furnished by 
the state of the heart for the use of stimulants it may not be in the power 
of all, without some experience, to avail themselves of it. The practi- 
tioner will, therefore, do well to attend to the following points, as directed 
by Dr. Armstrong, in forming his opinion of the propriety of persevering 
in the administration of wine to a patient in typhus fever : — 

" 1. If the tongue becomes more dry and baked, it generally does harm ; 
if it becomes moist, it generally does good. 

" 2. If the pulse becomes quicker it does harm ; if it be rendered 
slower, it does good. 

44 3. If the skin becomes hot and parched, it does harm ; if it becomes 
more comfortably moist, it does good. 

14 4. If the breathing becomes more hurried, it does harm ; if it becomes 
more deep and slow, it does good. 

44 5. If the patient becomes more and more restless, it does harm ; if 
he becomes more and more tranquil, it does good." 

The following observations on the use of wine and opium in fever 
were published in 1832, in the first volume of the Duldin Medical Journal. 

44 I have long endeavoured to impress on the minds of students, the 
great importance of studying with attention that stage of fever in which 
wine and opium are occasionally the best remedies, with a view of learn- 
ing what symptoms indicate their exhibition. In the commencement of 
fever, we can decide with a good deal of certainty upon the most proper 
course of proceeding, but as the disease advances, the symptoms become 
more complicated, the indications more confused, and the plan of treat- 
ment consequently doubtful. In this stage of fever it is that we must rely 
on the tact acquired by previous experience and reflection, and must often 
depend more upon a correct estimation of the general state of the patient, 
than upon the appearance or absence of any particular symptom. It is 
not my intention at present to do more than prove the truth of this asser- 
tion, by showing that the presence of some symptoms, commonly supposed 
to contra-indicate the exhibition of wine and opium, ought not to deter 
the practitioner from their use, provided that other circumstances seem 
urgently to require it : 

44 1st. In the first place, as to the tongue, at an advanced period of fever, 
I have often derived the greatest advantage from wine and opium, although 
the tongue was dry, the colour of old mahogany, or else coated with a 
yellowish brown fur, and protruded with difficulty, while the teeth and 
gums were covered with sordes. Wine and porter in moderate quanti- 



170 CLINICAL MEDICINE. 

ties seem generally to agree better with this tongue than opium ; in some 
cases, however, the latter is indispensable. 

M For fear of misleading the reader, I must again remark, I by no means 
wish to assert that such a tongue uniformly, or even frequently indicates 
the use of these medicines ; on the contrary, this state of tongue and 
mouth will often be observed at a time when leeches and the antiphlogistic 
treatment are required. Let it be clearly understood, however, that at 
an advanced period of fever, this state of the tongue may exist, and yet 
wine and opium may be given boldly, provided, as I have said before, 
the general state of the patient seems to require it. 

" 2dly. The observations I have made concerning the tongue are 
applicable to suffusion of the eyes. The eyes may be heavy, a little red, 
very much suffused, and may have the singular expression of watchful- 
ness, combined with great redness of the conjunctiva, which is termed a 
ferrety eye, and yet wine or opium may be the only remedy capable of 
saving the patient's life. It should always be borne in mind, that want 
of sleep tends to make the eye red, and that this condition is often, when 
it occurs in maculated typhus, analogous to the similar appearance of the 
eye which is observed both in measles and scarlatina, in which diseases 
it is merely a part of the general erythema, and does not contra-indicate 
the use of wine and opium if other circumstances call for their exhi- 
bition. 

" 3dly. A hot and dry skin does not necessarily contra-indicate the 
exhibition of wine and opium, particularly where there is at the same 
time a tendency to coldness of the extremities. 

" 4thly. The presence or absence of delirium must always excite our 
attention, when the question of giving wine or opium arises. I believe 
that these medicines are never applicable when the delirium is violent 
and continuous, but the patient may rave a great deal, particularly at 
night; he may mutter and speak to himself, he may point to various 
imaginary appearances, and may fancy himself surrounded by persons or 
things which have no real existence ; he may be restless and irritable, 
constantly endeavouring to leave his bed for the purpose of walking about 
the room, or sitting at the fire ; and yet he may be in a state urgently de- 
manding wine and opium. On a more accurate examination, we find that 
his delusions are not so strong as to leave no room for the exercise of his 
reason. When spoken to emphatically, he answers in some cases inco- 
herently, but in others, with perfect precision and presence of mind, and 
does not, for some minutes, relapse into his former wanderings. This 
state of mind is usually accompanied by an almost total want of sleep, 
and in many, by a great anxiety about their illness. To procure sleep, 
as has been well remarked by Latham, in a late number of the Medical 
Gazette, is here one great object, and this can only be done by means of 
wine and narcotics. In some the mental aberration is scarcely percepti- 
ble, and they have all the characters of great excitement of the nervous 
system, without any actual raving or delirium. There is general tremor 
and subsultus. The tongue is tremulous when protruded, or when moved 
in speaking, and consequently the articulation is uncertain and interrupted, 
while in general manner and mode of answering questions, the patient 
strongly resembles a person affected with delirium tremens.* This group 

* It is in these particular forms of fever that I have, since the appearance of the above paper, 
discovered the great utility of tartar emetic and opium. 



FEVER. 171 

of symptoms is likewise accompanied by want of sleep, and best treated 
with wine and opium. 

" 5thly. The appearance of the face has been much relied on by some, 
as capable of guiding us in forming our decision. Heat of head and face, 
redness of the cheeks, and strong pulsation of the carotids, are well 
known as contra-indicating wine or opium ; but in the advanced stages 
of fever, the face, like the eye, may be suffused, it may be seen occasion- 
ally flushed ; and when flushed, it may be hot, and yet wine and opium 
may, nevertheless, be our only resource. 

" 6thly. Headache, when violent, is at any period of fever a decisive 
circumstance. Sleep cannot be obtained while the pain is unmitigated, 
and we must, therefore, attempt to conquer it by the most active treat- 
ment, by local applications to the head, by depletion from the vascular 
system, and by purgatives. Sometimes, however, these means fail, and 
the physician feels that he cannot pursue this mode of treatment any fur- 
ther. Under such circumstances, a dose of opium boldly exhibited, will 
occasionally succeed in procuring sleep, from which the patient awakes 
nearly free from headache. Before having recourse to this remedy, the 
effects of a blister to the nape of the neck ought to be tried. In the more 
advanced stages of fever, the headache, or rather the heaviness felt in the 
head, is something very different from the throbbing, acute headache, just 
spoken of, and constitutes no contra-indication to the use of wine and 
opium. 

" 7thly. The state of the pulse requires to be duly considered. Its fre- 
quency is not of much importance, for I have seen wine and opium prove 
highly serviceable in all its varieties, from 70 to 130, or even upwards. 
No one would ever think of exhibiting these remedies when the pulse is 
strong, and more particularly when it is strong and hard ; but the case is 
otherwise when it possesses only a certain degree of hardness, and is at 
the same time small and thrilling, not resisting compression with the force 
the sensation of its hardness leads us to expect. 

" Such are the chief observations I have made on the particular circum- 
stances and symptoms supposed capable of throwing light on this import- 
ant practical question. They may serve to prevent the student from being 
misled by rules of practice dogmatically deduced from the observations of 
any single symptom, and may lead him to turn his attention more accu- 
rately to the previous progress of the fever, and the general state of the 
patient. It is almost superfluous to add, that when any doubts exist 
concerning the propriety of giving wine and opium in fever, they should 
not be tried unless their effects be carefully watched by the physician 
himself." 



LECTURE XVI. 

Case of long-continued nervous fever — Remarks on. 

Permit me to make one or two observations on a case of which I have 
already spoken, and which, as I expected, has terminated fatally. A man, 
named Lynam, has been lying ill for a long time in the large fever ward; 
1 wrote at the top of his card " Nervous Fever," and remarked to the 



172 CLINICAL MEDICINE. 

class that his disease was pure fever, of a nervous type, unaccompanied 
by any symptoms indicating decided local inflammation. You will recol- 
lect that his symptoms were heat of skin, quick, weak, compressible 
pulse, thirst, watchfulness, and low muttering delirium, unattended by 
any appreciable sign of visceral disease, or any symptoms denoting a pu- 
trescent state of the fluids. It was not congestive or putrid, or gastro- 
enteric, or petechial fever ; neither could it be called a cerebral fever ; it 
was only by separating from it the idea of each of these species, and by 
studying its negative characters, that you could arrive at something like 
an accurate conception of the type of the disease. It was, as I have 
already stated, nervous fever, modified by the patient's previous habits of 
long-continued intemperance. When a patient, addicted to intemperate 
habits, gets an attack of fever from cold, fatigue, or exposure to contagion, 
you will generally find the disease will exhibit a compound or mixed 
character, the phenomena of fever being combined with those of delirium 
tremens. And so it was in this case ; the man had general tremors, with 
persistent watchfulness, and muttering delirium. 

His treatment consisted in the employment of medicines calculated to 
soothe the nervous system, and I kept a constant watch over the state of 
the principal viscera. About a week after he came under my care, and 
about five weeks from the commencement of his fever (for he was nearly 
a month ill before he came to the hospital), he was attacked with erysipe- 
latous inflammation of the face and scalp. The disease commenced on 
the face, and, travelling upwards, very rapidly attacked the whole scalp 
and back of the neck, its progress being accompanied by great aggrava- 
tion of symptoms. At that time I remarked to the class that I did not 
entertain any apprehensions of a metastasis of the erysipelas, that I had 
no fears of the supervention of inflammation of the brain, and its train of 
alarming consequences ; but that no good was portended by this attack of 
cutaneous inflammation, and no relief of the internal parts could be ex- 
pected from it, for every symptom appeared aggravated from the moment 
that the erysipelas commenced. I pointed out the total inadmissibility of 
any thing like vigorous or antiphlogistic treatment, in a case where the 
disease had appeared in an individual of broken constitution, labouring 
under a combination of delirium tremens with low fever ; and said that 
even the remedy which we had found most successful in similar cases, 
namely, sulphate of quinine and opium, offered but a feeble hope of arrest- 
ing the malady. It failed, as we expected, and the man died yesterday, 
worn out by long suffering and exhaustion. Eighteen hours after death 
w r e made a most careful examination of all the viscera of the three great 
cavities ; not a single organ exhibited the least mark of inflammation ; we 
could not find any where even the slightest trace of local congestion. The 
man had all his viscera in an apparently sound and normal condition, and 
died of pure nervous fever. 

Some persons look upon the existence of fever independent of topical 
affections as purely imaginary, and deem those, who have recorded such 
forms of disease, as too ignorant, or too lazy, to make the necessary pa- 
thological investigations. I have not time at present to enter into this 
subject, but of nothing am I more convinced, than that fever may exist 
without any appreciable local lesion, that it may affect every organ and 
every tissue of the body alike, and yet that the most accurate symptoma- 
tologist cannot put his finger on any one single part and say, here is local 



FEVER. 173 

inflammation of a derided character. I have met with many instai ces 
confirmatory of this fact in hospital practice. I recollect a case which 
occurred some time ago at this hospital, which was equally remarkable 
for its extraordinary duration, as for the total absence of any thing like 
visceral lesion. The patient was admitted into the small fever ward, 
labouring under an attack of nervous fever ; he had thirst, hot skin, pulse 
from 110 to 120, occasional delirium and watchfulness, and these symp- 
toms went on week after week, and month after month, unaccompanied, 
during the whole course of the disease, by any phenomena indicating the 
existence of local inflammation. His treatment was purely expectant and 
temporising ; we had no cerebral, abdominal, or thoracic lesion to com- 
bat ; there was no organ in which the febrile derangement could be said 
to have fixed itself exclusively, no threatening disorganization calling for 
the employment of prompt, new, and energetic means. At last, after the 
fever had continued for very nearly three months, the man complaining 
all the time of more or less thirst, hot skin, watchfulness, and headache, 
with occasional delirium, the disease terminated in a well-marked crisis, 
accompanied by sweating. He fell asleep, began to perspire, awoke with 
a pulse nearly reduced to the natural standard, and perfectly recovered. 
I may observe that I have never seen fever last so long as this, nor have 
I ever observed a perfect crisis in any case after the forty-second day. 
Some time ago I attended the brother of a gentleman now present, who 
had a long and very severe attack of fever ; though he never had a re- 
mission during his illness, and was in very urgent danger, he got a per- 
fect crisis with profuse perspiration on the forty-second day, and is now 
in the enjoyment of excellent health. 

You perceive then, that the case of Lynam presents some circumstances 
worthy of notice. His fever went on to its termination without any symp- 
toms of inflammation in any viscus, and his actual condition, as carefully 
ascertained by an accurate post-mortem examination, affords a useful les- 
son to the pathologist. His case is also interesting as showing how pre- 
vious habits will modify in a remarkable degree the character of fever ; 
for in him you have seen fever combined with the phenomena of delirium 
tremens, a state of things which it was natural to expect in a man of ex- 
tremely intemperate habits. The termination of the erysipelas without 
any sign of disorganization within the cranium is also worthy of notice. 
In such cases you have it frequently followed by inflammation of the brain 
and its membranes, and an exudation of pus on the surface of one or both 
the hemispheres ; but here you perceive that there has been no extension 
of the disease or nothing that should have induced us to give up the plan 
of treatment we adopted, and direct our therapeutic means to the head. 

There is another man, named Vero, in the fever ward, w T hose case I 
beg you will study with attention. He applied for admission here some 
time ago, labouring under violent and general bronchitis, accompanied 
with high inflammatory fever ; w T e took him in at the time, as his case was 
one of the most urgent danger, but were obliged, by the crowded state 
of the hospital, to put him into the large fever ward. It is unnecessary 
for me to detail the treatment employed, as you have all witnessed it. 
By the most energetic measures, we succeeded in arresting the disease, 
but his convalescence was rendered tedious in consequence of his having 
been suddenly affected by a small quantity of mercury. His mouth be- 
came very sore, his breath fetid, his gums spongy, the inside of his lips 



174 CLTNICAL MEDICINE. 

covered with lymph, and his system exhibited all the marks of mercurial 
irritation ; but, under the care of Mr. Grady, a gradual but decided im- 
provement in his condition was going on, and he was advancing rapidly 
in convalescence, when, unluckily for himself, he was persuaded to leave 
the hospital for the sake of voting at the city of Dublin election. In doing 
this, he was necessarily much fatigued, and was exposed to cold on re- 
turning from the heated booth. Now, mark the consequences of this in- 
discretion. This man just arrived at the period of convalescence from a 
severe and dangerous inflammatory fever, and greatly debilitated both by 
the disease and the venesections and other remedies necessarily employed, 
improvidently exposes himself while his frame was still emaciated and 
weak, and w T hile his mouth was still sore in consequence of severe mer- 
curial salivation ; in this condition he exposes himself to the operation of 
mental excitement, great bodily fatigue, and cold — and what have been 
the consequences? Why, that a new attack of fever immediately struck 
him to the ground with a heavy hand, and, after an absence of ten days, 
he returned to the hospital on the 24th of January, complaining of rigors, 
and other symptoms indicative of commencing fever. We saw him next 
morning, that is, before this new fever had lasted more than twenty-four 
hours, and we found him affected in a most remarkable manner ; we 
found him labouring under a number of severe symptoms, which would 
have led the most experienced, if asked to guess how long his fever had 
already lasted, into the commission of a gross error, for he would answer 
that it must be at least the eleventh day. It is, indeed, very rare to find 
fever at once commencing with symptoms such as we observed on the 
first day in Vero. Great prostration of strength, hot skin, dry tongue, 
pulse 108, nervous agitation, restlessness, together w T ith subsultus tendi- 
num, were present from the commencement. The subsultus was very 
remarkable, and increased to such a degree, even on the second day, that 
Mr. Grady found it very difficult to count the pulse at the wrist ; and yet, 
though his muscular system was thus irregularly excited, and its nervous 
influence deranged, he had not even a tendency to delirium, and he slept 
soundly ; neither had he the least headache. 

I called your attention to this circumstance at the bedside of the patient, 
and I endeavoured to impress strongly on your minds how forcibly this 
case opposes the doctrines of those who attribute all the nervous disturb- 
ance of every part of the system, and, among the rest, subsultus, to con- 
gestion or to inflammation of the brain. When the subsultus had attained 
to a degree of violence in Vero's case, such as w T e seldom witness, we 
remarked, nevertheless, that he slept well, had a clear eye, without the 
least approach to suffusion, and that he was free from headache, heat of 
scalp, or throbbing of the temporal arteries. Neither were we able to 
detect the slightest indication of inflammation, or even of congestion, in 
the chest or abdomen. The breathing was indeed quickened, but only in 
proportion to the acceleration of the pulse, and there was no cough or tho- 
racic pain or uneasiness. The belly was fallen, soft, and quite free from 
tenderness; and there were no griping pains, flatulence, nausea, or diar- 
rhoea, and yet the patient was evidently very dangerously ill. Agitated 
with subsultus, he was in a constant state of restlessness when awake ; his 
skin was hot, his tongue dry, and his weakness was sudden and excessive ; 
in short, he was labouring under intense nervous fever. This is a rare form 
of disease, and one the very existence of which most modern pathologists 



FEVER. 175 

have been in the habit of denying; but, as I told you in a former lecture, 
I have seen several examples of it. 

I may remark that, in the present epidemic fever, the termination of the 
disease by a well-marked crisis never occurs. Now, in the epidemic fever 
of which I have spoken in a former lecture, and which committed such 
devastations in 1826, a crisis was observable in the majority of the cases, 
and was almost always preceded b) rigors and a hot fit, attended for a few 
hours with marked exacerbation of the symptoms, and followed by a most 
profuse, warm, general perspiration, bringing perfect relief, and often so 
excessive that the steam of it could be seen issuing forth in vapour through 
the blankets in which the patient lay wrapped. In the beginning of the 
epidemic, the critical rigor often took place on the fifth day, and oftener 
on the seventh, but, as the disease continued, these short fevers, which, 
by the by, always left the patient very liable to relapse, entirely disap- 
peared ; and when the epidemic reached its acme, the crisis rarely took 
place so early as on the eleventh day, and most generally on the fourteenth 
or seventeenth day. 

You perceive, that in judging of the truth of the doctrines held by the 
ancients, concerning the existence of critical days in fevers, an observer 
of the present epidemic might be led into error, and might, by generalis- 
ing too hastily, arrive at the false conclusion that this doctrine of critical 
days is totally destitute of foundation. But to return to our patient Vero. 
It is not very difficult to explain why, in him, the moment fever was ex- 
cited it assumed the nervous type. He had been debilitated by severe 
inflammatory fever and by active antiphlogistic treatment, and, above 
all, his nervous system had been severely tried by an unexpected mercu- 
rial salivation, brought on by an unusually small quantity of calomel. 

You are aware that various nervous symptoms attended with irregular 
muscular action, and simulating chorea, or paralysis agitans, are frequently 
the result of metallic salts, whether lead or mercury. For this reason, I 
look upon the previous mercurialization as the chief cause of the nervous 
type of Vero's fever. In spite of all our efforts, he died exhausted on the 
tenth day. 



LECTURE XVII. 

Prescriptions in Fever. 



I shall speak to-day of some prescriptions which I am in the habit of 
using in the treatment of fever. In the treatment of fever it is frequently 
of importance to gain time, and periods will occur in every long fever, in 
which there may be no direct indication for the exhibition of any power- 
ful remedy ; at the same time, such is the. ignorance of non-medical per- 
sons, and the anxiety of the patient's friends is so intense, that they can- 
not imagine how it is possible for an attentive physician to let twelve hours 
pass away without doing something. The mere circumstance of seeing 
the fever going on, is sufficient proof to them of the necessity of making 
renewed efforts for its removal. This, however, is very excusable. If 
any of you happened to be ill, I dare say you could scarcely bear to pass 
many hours without taking something which you supposed might prove 



176 CLINICAL MEDICINE. 

either immediately or remotely useful. Consequently, we could not treat 
fever in a satisfactory manner without medicines of what may be termed 
an expectant character, and calculated to fill up the spaces intervening be- 
tween those periods when active treatment is necessary. You are not to 
suppose that in ordering such medicines you are acting a dishonest part, 
and practising a deception unworthy of your profession ; on the contrary, 
your conduct is perfectly just and proper; and though you are convinced 
that no medicine is required, still it will be necessary to prescribe some- 
thing, if you do not wish to lose the confidence of the patient and his friends. 
Again, if at a period when you say that no medicine is necessary, and 
when the patient has passed twenty-four hours or two days without taking 
any thing, an unexpected turn in his disorder should take place, people 
will be very apt to say, either that you did not know what to do, or that 
you took no steps to obviate the threatened change, and that one or two 
days were completely lost. Conduct like this has frequently brought down 
a great deal of censure on medical men. It may be said that these are mere 
prejudices, and above the dignity of a man of firm and consistent charac- 
ter; but since prejudices are intimately blended with human nature, and 
constitute, as it were, a part of it, it is much better in many cases to sub- 
mit to them, particularly when compliance does not involve a sacrifice of 
principle. In cases of acute disease of any considerable duration, and 
especially in private practice, there are periods when medicines of an ex- 
pectant and temporising character must be employed, and hence the intro- 
duction of a class of remedies extensively used in fever and other com- 
plaints, and generally denominated palliatives. These are remedies which 
have a general tendency to assuage thirst, act as diluents, gently promote 
the secretions of the skin, intestinal canal, or kidneys, and which are known 
to possess at least the negative quality of doing no harm. They are most 
commonly prescribed in combination with a considerable quantity of fluid, 
and hence are administered either in the form of draught or mixture. The 
medicine in most general use among the physicians of Dublin is one which 
was introduced by Dr. Cheyne. It is prepared by dissolving a drachm of 
carbonate of ammonia in three ounces and a half of water, with as much 
lemon-juice as will saturate it; the mixture is then sweetened with syrup 
of orange-peel, and given in doses of two tablespoonfuls every third or 
fourth hour. In this way a solution of the citrate of ammonia is formed 
which possesses the properties of a mild antifebrile, and gently stimulant 
diaphoretic. 

Now it cannot be denied that this mixture answers the purposes of an 
expectant remedy, calculated to pass away the time, and do no injury ; 
but it appears to labour under one considerable disadvantage, it is not 
agreeable to the taste. If you taste the citrate or acetate of ammonia, 
you will find that its flavour is by no means pleasant, and I need not tell 
you that in cases where there is no actual indication to be fulfilled, it is 
of importance to have^something that will not be disagreeable to the patient. 
Feeling, therefore, the necessity of altering this prescription, I have lately 
introduced another, which I am happy to find has been extensively adopted, 
and which is formed by substituting the carbonate of soda for the carbonate 
of ammonia. The mode in which I generally employ it is the following : — 
carbonate of soda, a drachm ; water, four ounces ; lemon-juice, a sufficient 
quantity to saturate the alkali ; syrup of orange-peel, half an ounce ; tinc- 
ture of orange-peel, two drachms. A little more than an ounce of lemon- 



FEVER. 177 

juice will be sufficient to saturate this quantity of carbonate of soda, 
whereas it would take from two and a half to three ounces to saturate the 
same quantity of carbonate of ammonia. If you wish to have a weaker 
solution, and I believe it is the better way, you can dissolve a drachm of 
carbonate of soda in five ounces of water instead of four. Nothing can 
be more agreeable in flavour than this mixture. The citrate of soda 
which is formed, does not, it is true, exert any active influence on the 
animal economy, but it partakes in the properties of neutral salts, deter- 
mines gently to the kidneys, tends to keep up a soluble state of the 
bowels, and forms a most grateful and refreshing beverage. The syrup 
of orange-peel gives the mixture an extremely pleasant flavour, and this is 
further heightened by the agreeable aromatic bitter of the tincture. Since 
I commenced using it, 1 have found it to answer all the necessary pur- 
poses extremely well, and I can recommend it to you with confidence. 

A woman, named Anne Scarlet, was admitted on Saturday, concerning 
whose case it may be necessary to make a few observations. She states 
that she has been ill for the last eight days, and that her illness originated 
in cold, preceded by rigors, and followed by feverish symptoms. The 
general pyrexia had subsided at the period of her admission ; but she had 
some symptoms worthy of attention. Her pulse was 72, and regular; 
her skin rather cool, and her bowels natural ; but she complained of acute 
pain in the left side, which, she said, came now and then, catching her 
breath, and preventing her from taking a full inspiration. This pain was 
so intense, and seemed to affect respiration so considerably, that, looking 
to its situation and its effects, you would at first sight be inclined to think 
that it arose either from pleurisy or pericarditis. On examining the chest, 
however, by the stethoscope and percussion, we found the sound was 
clear and normal : there were no rales present, and the respiratory mur- 
mur was heard distinctly over the whole lung. In fact, auscultation 
showed that the cause of the pain was not connected with pleuritis, pneu- 
monia, or pericarditis. What then was it ? A variety of pleurodynia, 
well worthy of your attention, as being connected in her case with 
retention of the milk and engorgement of the left mamma. At the time 
she was attacked with cold, she happened to be only a few days after 
childbirth : the feverishness which ensued obliged her to give up nursing, 
and in this way a sudden and unnatural check was put upon the secre- 
tion of milk. When an occurrence of this kind takes place, and proper 
means are not taken to obviate the mischief, a high degree of local irrita- 
tion is the consequence, producing inflammation of one or both the 
mamma?, which, if not treated well and energetically, will certainly end 
in mammary abscess. 

What I wish to draw your attention to, however, at present, is this — that 
inflammation of the mamma, arising from retention of milk, is very apt 
to be attended with pleurodynia in one or more parts of the chest. 
The flow of milk to the breasts, three or four days after delivery, is very 
often accompanied by flying pleurodynia, and the formation of mammary 
inflammation, from the arrest of the lacteal secretion, is also very frequently 
attended with fixed pains of a pleuritic character. 

The treatment adopted in this case was very simple. In the first place, 
you endeavour to check the determination of fluid to the breast ; and for 
this purpose you exhibit a purgative of a hydragogue kind, calculated to 
act briskly on the bowels. We gave a combination of infusion of senna, 
13 



178 CLINICAL MEDICINE. 

sulphate of magnesia, tincture of senna, and electuary of scammony, which 
acted six or seven times on the bowels, and tended materially to relieve, 
by derivation, the mammary congestion. In the next place, we directed 
our attention to the breast, and endeavoured to remove the milk, by the 
use of the syringe employed for that purpose. The milk may be removed 
from the breast by means of the syringe, or by sucking with a breast- 
bottle, and where the tenderness of the part is so great that neither of 
these modes can be employed, the next best means is diligent fomenta- 
tion. This produces a constant oozing from the breast, and if the fomen- 
tation employed be made with a decoction of poppy-heads, it has consi- 
derable effect in abating pain and inflammation. We also applied leeches 
in this case, not with the view of removing the pleurodynia, but with the 
intention of removing its cause, mammary inflammation. By the use of 
means directed to the breast, you will find that we can remove all symp- 
toms of pleurodynia, and that the pain and difficulty of breathing will 
soon disappear. This is a simple case, but it is one of frequent occur- 
rence, and it requires some tact and management for its successful treat- 
ment. 

You have probably observed that, in the treatment of all the cases that 
came before me, I have not prescribed altogether a dozen grains of calomel ; 
that I have very seldom ordered any kind of purgative medicine ; that I 
have been sparing in the use of leeches and cupping, and that I have not 
ordered a single patient to be blooded.* This I am sure will appear 
strange to the various sects of pathologists and theorists whom I have 
seen, like so many waves, succeeding each other, and whose doctrines 
were equally doomed to break on the solid and immovable shore of truth. 
I recollect how each doctrine arose, and made converts, and influenced 
practice ; how each had its day, and then sank into that obscurity and 
neglect to which vain and profitless speculations are always destined. I 
recollect w T hen it was the custom to commence the treatment of fever, by pre- 
scribing ten grains of calomel, to be followed by a bolus containing fifteen 
grains of jalap, or by a large draught composed of infusion of senna, 
epsom salts, and electuary of scammony. I remember the time when it 
was the fashion to bleed every case of fever which came into hospital, no 
matter what the stage of the disease might be, or what the condition of 
the patient was at the time of admission. I recollect, too, when the pros- 
tration and weakness which accompany local inflammation, particularly 
of the digestive system, used to be treated with wine and stimulants. 
Every epidemic is peculiar and distinct in its nature, and each conse- 
quently requires a distinct and peculiar mode of treatment. Hence the 

* [There is no doubt that Dr. Graves is perfectly right in avoiding 
bloodletting, mercurials or powerful purgatives.. None of these reme- 
dies is adapted for the treatment of typhus fever. There is no doubt that 
any one who has seen many cases of the disease would be quickly con- 
vinced of the propriety of using all these remedies very sparingly ; in fact 
general bloodletting was not prescribed for a single patient during the last 
summer at the Pennsylvania Hospital, nor did we see a case amongst the 
whole number in which it seemed to be indicated. In the typhoid fever 
a different course is often required, but in true typhus we have no doubt 
that the physician should carefully abstain from any debilitating modes of 
treatment.— W. W. G.] 



FEVER. 179 

necessity of studying fever unbiased by any preconceived notions, and 
independent of the trammels of dogmatism. With a person who observes 
in this way, who studies the disease as it is, and not as it is described ; 
whose practice is regulated, not by the doctrines of the schools, but by 
the results of investigation, carefully weighed and considered ; with such a 
person, the treatment of fever will be simple and successful, and I believe 
that there is no disease in which success so much depends on treat- 
ment as fever. It is difficult to explain how it came to pass that a con- 
trary opinion could be promulgated in Dublin. Something must be 
attributed to the neglect or incapacity of those whose duty it was to teach 
the truth. The chief cause may, however, be traced to the activity and 
zeal which inspired some, not only to uphold their own branch of the 
profession, but to decry, I had almost said to defame, that which they 
were pleased to call pure medicine. With characteristic inconsistency, 
however, these gentlemen, who declared that the treatment of fever was 
at best useless, readily engaged in its management in private practice, 
and while they professed openly their disbelief in the efficacy of any 
medicines, they busily employed themselves in prescribing pills and 
draughts without number for their own fever patients. That they thought 
their treatment of some value, might be gathered from their acceptance, 
their invariable acceptance, of pecuniary remuneration from their sufferers' 
grateful friends, who little dreamed the while that the hands, which, with 
automatic movement, so readily grasped their fees, belonged to persons 
who held, nay, w T ho maintained, the opinion that the treatment of fever 
was all a farce. Posterity will scarcely give credence to this fact, and 
will probably refuse to believe that such an opinion could have been 
advanced in what we are pleased to call an enlightened age, and an 
enlightened city. They will scarcely think I speak the truth in assuring 
them that a spirit of medical intolerance existed to such a degree at the 
time of the discovery of the stethoscope, that whoever in Dublin actively 
occupied himself in verifying the researches of the immortal Laennec — 
whoever availed himself of the new resources invented by this great phy- 
sician was sure to become an object, not merely of dislike, but of animad- 
version and ridicule, on the part of those w T ho ought to have exerted their 
influence in endeavouring to advance, and not to retard, the progress of 
science. Happily for the character of the country, their endeavours have 
been frustrated, and the cause of truth has triumphed. Happily for the 
students and their future patients, those teachers are now most followed, 
who best explain, and most diligently illustrate, the phenomena observed 
by means of mediate auscultation. 



LECTURE XVIII. 



Yellow Fever — Account of the yellow fever at Gibraltar — \t. Louis's researches — Yellow fever 
of Dublin — Notes of clinical lectures delivered in 182C upon this subject — Contractility of 
efferent ducts. 

In the epidemic of 1826, we had several cases in the Meath Hospital that 
presented all the characters of yellow fever. This is a very remarkable 
fact, for this form of fever has not since appeared in this country, nor has 



180 CLINICAL MEDICINE. 

it been observed in any part of Europe, to tbe nortb of Cadiz, Gibraltar, 
and other towns of Andalusia. The last epidemic of yellow fever in 
Gibraltar is described by Louis, who with Trousseau and Cherrin was 
sent by the French government to investigate the disease. I shall quote 
from his report an account of the symptoms and post-mortem appearances 
which they observed, and compare it with the description of the yellow 
fever of 1826, printed by myself and Dr. Stokes, for the use of the pupils 
of the Meath Hospital. 

" GENERAL DESCRIPTION OF THE SYMPTOMS OF THE YELLOW FEVER EPIDEMIC, 

AT GIBRALTAR, IN 1828. 

" The disease spared neither sex nor age ; men and women, young and 
old, were alike its subjects. Those only were exempt from its influence, 
who had gone through with the disease in a former epidemic. 

" It commenced at different hours of the day, sometimes in the night, 
sometimes fasting or soon after eating, usually with an intense headache, 
accompanied by chills, shivering, pain in the limbs, and soon after pain 
in the back. A heat, rarely intense, succeeded to the chills, and was 
sometimes followed by perspiration. At the same time the countenance 
became red and animated; and in some cases, as it were, swollen. The 
eyes were red, glistening, suffused, and in many cases the patients com- 
plained of a sensation of smarting in them. The thirst was intense, the 
anorexy complete. It was rare that the patient suffered any pain in the 
epigastrium at this period. 

" The first symptoms, the headache, the pain in the limbs, the anorexy, 
the thirst, the heat, the redness, and the pain in the eyes, continued, the 
headache during half the disease, the pains in the limbs a little longer, 
and the heat, which in many cases was but slightly increased, continued 
so during nearly the same time. 

" The pain in the epigastrium, so rare at the commencement, came on 
usually fifteen or twenty hours later. It was generally inconsiderable, 
and very few patients complained of severe, or acute pain. With the epi- 
gastric pain came the nausea and vomitings, excited by drinks and pur- 
gatives in several cases, spontaneous in others. The dejections were in- 
frequent, that is where no laxatives had been administered. The abdomen 
preserved its form, was supple and indolent, except in the epigastric re- 
gion. The sleep was inconsiderable — some patients were restless, in some 
there was a good deal of jactitation during the night; others, and the 
smaller number, experienced as early as the third day, a real anxiety, 
could not remain quiet in any posture, and in some cases there was deli- 
rium. But this symptom did not usually come on till the last day of life ; 
and for this reason it is to be considered rather as belonging to the agony 
than to the disease ; otherwise, with few exceptions, there was neither 
prostration nor stupor. The pulse was moderately accelerated, regular, 
generally bearing relation to the degree of heat, which was almost always 
slight, as I have before said. The skin of the thorax was injected in 
some cases. This redness and that of the eyes, diminished toward the 
middle period of the disease, or a little later, and new symptoms appeared. 
To the injection of the integuments of the chest there succeeded a slight 
yellow tint of that part, and the eyes wore the same colour. When this 
colour appeared thirty-six or forty-eight hours before death, it became 



FEVER. 181 

rapidly brighter, so as to be of considerable intensity at the time of the 
fatal termination. In other cases where it came on onlyjust before death, 
it was slight at the autopsy, and commonly limited to the trunk. At 
about the same period, or a little later, the matter vomited and the dis- 
charges from the bowels, which up to that time had presented nothing 
remarkable, took on a certain character which they have not in the course 
of the acute diseases of Paris. The dejections were blackish or bluish, 
and the matter vomited, from being of a yellow colour, became brown or 
black. At the commencement of this change of colour, the vomit was of 
a liquid matter, more or less greyish, mixed with a greater or less quan- 
tity of mucus, in which were to be seen blackish parcels, like soot. 

" At this period of the disease, the uncomfortable feelings and the 
anxiety continued during different lengths of time, and in different de- 
grees, the strength diminished, the temperature fell, so that the limbs 
were cold before the agony ; in a certain number of cases there was a 
suppression of urine. Sometimes also we observed a sort of remission, 
an apparent amelioration of the symptoms, and death took place when it 
would least have been expected, had not experience taught us to distrust 
his deceitful remission. In some subjects the violence of the headache, 
that of the pains of the limbs, the marked febrile symptoms, the numerous 
vomitings, the uncomfortable feelings, the anxiety, the bright redness of 
the eyes, gave to the disease a truly serious aspect ; whilst in others the 
mildness of the fever, and of the pains wherever seated, the absence of 
agitation and delirium, the slight diminution of the strength, impressed 
on the disease a character of mildness, calculated to deceive at once the 
patients, their attendants and the physician. It is under this form of the 
disease that patients died without taking to their beds — on foot, as it was 
expressed by their friends. Thus Dr. Mathias, who died after an illness 
of four or five days, experienced no other symptoms but severe pains in 
the calves of the legs, and a suppression of urine. He had no nausea ; 
he did not vomit ; his mind was perfectly clear during the whole course 
of the disease. * * * * 

u This kind of latent condition of the yellow fever does not distinguish 
it from the acute diseases of Paris, which also are often obscure, and their 
symptoms mild ; but it is remarkable on account of the rapid progress of 
the disease, usually fatal from the fourth to the sixth day. And this latent 
form reminds us at once of certain facts of poisoning by arsenic, in in- 
stances of individuals who have retained their clearness and calmness of 
mind, from the moment of swallowing the poison until their death. 

U I add, that the severity of the symptoms does not correspond always 
with that of the lesions. Of these last, one only was constant, the specific 
alteration of the liver. The inflammatory state of the mucous membrane 
of the stomach comes next in frequency, and sometimes explains in a man- 
ner sufficiently satisfactory the symptoms that had been observed." — Louis 
on Yellow Fever, translated by G. C. Shattuck, Jun. M.D. page 167. 

PRINCIPAL MORBID APPEARANCES DISCOVERED IN FATAL CASES. 

The following are the appearances which Louis discovered in the fatal 
cases of yellow fever at Gibraltar: — * 

* I have intentionally omitted the very minute description of the thoracic viscera, the brain 
spinal cord, &c. ; suffice it to say, there was nothing observed worthy of note. 



182 CLINICAL MEDICINE. 

u The stomach was larger than natural in seven subjects, smaller than 
usual in three. It contained a clear or dark red coloured liquid, a black- 
ish or a perfectly black fluid, in different quantities, in three-quarters of 
the cases. Its mucous membrane was red through, a greater or less ex- 
tent, in six cases; rose-coloured or orange in eight cases ; greyish, yellow- 
ish, or whitish in the others. It was thickened through a greater or less 
extent of surface in half the cases; softened and yellow to an extreme 
degree in the same number; at the same time thickened, softened, and 
red in a third part of the cases ; mamelonated in two-thirds; ulcerated in 
two cases ; it was natural in five cases. 

"The mucous membrane of the duodenum was red in a little more 
than half of the cases; softened in the same number; and thickened in 
one case. 

" The small intestines contained a greater or less quantity of reddish, 
brownish, blackish, or perfectly black matter, in two-thirds of the cases. 
Its mucous membrane was slightly injected or red in spaces, in a little 
less than half the cases. Its consistence was more or less diminished 
through its whole length, or through a part of its extent only, in rather a 
greater number of cases. It was partially thickened in one case; in no 
case was it ulcerated ; and Peyer's glands were always natural. 

The large intestine was of a greater size than usual in two cases. In 
fifteen cases it contained a matter of a wine lees colour, or blackish, or 
brownish, or chocolate-coloured, or entirely black. Its mucous membrane 
was of a pale or bright red colour in five cases; greyish, yellowish, or 
whitish in the others. Its consistence was more or less diminished in 
three-quarters of the subjects. Its thickness was increased in three cases; 
and twice we found it slightly ulcerated. 

"The mesenteric glands presented traces of inflammation in four cases; 
the cervical glands in one case; in another case one of the glands above 
the biliary ducts was red, softened, and very large. 

" The liver was of greater size than natural in two cases; a little firmer 
than usual in three cases ; a little less firm in three others. Its cohesion 
was increased in six cases, diminished in seven. Its colour was altered 
in every case, sometimes it was of the colour of fresh butter, sometimes of a 
straw yellow, a clear coffee and milk colour, sometimes a gum yellow, some- 
times of a,n orange colour. 

"The spleen was softened in eight cases, and to a moderate degree, 
with one exception. It was larger than usual in five cases. 

" The lesions which we have thus placed before the reader, were rarely 
considerable, very often insufficient, to explain the death, and when this ex- 
planation was afforded, it was by a combination of several lesions. 

"These lesions maybe divided into two classes, some of them peculiar, 
or almost exclusively peculiar, to subjects dying of yellow fever; others 
common to those subjects, and to subjects who have died of other acute 
diseases. The red or black matter found in the alimentary canal, and the 
remarkable alteration of the liver, are of the first class, all the other lesions 
of the second. 

" The red or black matter of the stomach or intestines not having been 
found in all the cases of yellow fever, it cannot be considered an anato- 
mical character of the disease. But it is not so with alteration of the 
liver, which was more or less exactly the same in all the cases, and which, 
for that reason, ought to be considered as the essential anatomical charac- 
ter of the yellow fever of Gibraltar, of 1828. 



FEVER. 183 

" Amongst the lesions of the second class, the yellowness and the in- 
flammation of the mucous membrane of the stomach should be especially 
remarked, as well from their frequency as on account of the rapidity with 
which they came on. The inflammation of the mucous membrane of the 
stomach not having taken place in all the cases, and Peyer's glands not 
having ceased to be natural, it follows on the one hand, that the yellow 
fever of Gibraltar, of 1828, is not a gastritis, and on the other hand, that 
it is not a typhoid fever. This last conclusion is even more strict ; for 
not only was there an absence of the lesions of typhoid fever in the bodies 
of the victims of yellow fever, but these bodies presented other lesions 
which are not found in the victims of the first disease, and which are 
peculiar to the second disorder. 

" What, then, is the nature of the yellow fever of Gibraltar, of 1828, 
and where is the seat of it ? If it be neither a gastritis nor a typhoid 
fever, neither is it a hemorrhage, as it has lately been said to be, for the 
hemorrhage did not take place in all cases. Is it a disease of the liver ? 
Undoubtedly the liver was the organ principally and essentially alfected ; 
still we cannot regard the yellow fever as simply a disease of the liver, 
because its lesion, at least in the present condition of science, does not 
explain the febrile symptoms in the cases where this was the only lesion ; 
and in the second place, because it is entirely insufficient to explain the 
death. 

" As, then, a strict analysis of the anatomical appearances of the yellow 
fever of Gibraltar, of 1828, proves the existence of a cause unequal in 
its operation, and of which but one effect is constant, the specific altera- 
tion of the liver, and as in a third part of the cases, it is directly to this 
cause that we are obliged to refer the death, we naturally ask, how does 
this act, through the medium of what system does it exert its influence on 
the economy ? Is it through the nervous system, is it through the blood, 
in which, however, we have not detected any especial modifications?" — 
Louis on Ye/ low Fever, translated by G. C. Shattuck, Jun., M. D., 
page 160. 

Now we come to the Epidemic of Dublin. 

John Gall, aged 35. Admitted about 10th January. Date of illness 
unknown ; probably about seven or eight days. Tenderness of epigas- 
trium chief symptom, and costiveness ; skin hot; tongue very dry and 
brown in centre ; edges white ; a little moist ; much debility ; appeared 
stupid, but no delirium ; memory uncertain ; at one time he said he was 
two days ill, at another for several ; belly hard, full. — Leeches to epigas- 
trium, and purgatives with apparent relief. — Next day he got effervescing 
draughts, and began to complain of cough. — Blister on the chest on the 
following day. — That night he became yellow, being convulsed in belly, 
and died at 5 a.m. yesterday. — Dissection 30 hours ajter death. — Body 
well made, strong, muscular; skin and conjunctivae yellow: posterior 
parts livid. Dura mater yellow ; no fluid between dura mater and arach- 
noid ; considerable quantity of fluid under arachnoid, between convolu- 
tions, of amber-yellow colour ; brain remarkably firm ; substance white ; 
yellow fluid in right ventricle and also in left, in anterior cornua, in con- 
siderable abundance, particularly in left. — Abdomen. Liver natural; no 
obstructions in ducts; bile in gall-bladder; stomach of a dark purple 
colour universally ; raucous membrane increased in thickness ; bleeds 
when torn ; is evidently a little softened ; villous coat like velvet ; when 



184 CLINICAL MEDICINE. 

in water villosities whitish and floating. Near the pylorus we observed a 
very curious and beautiful appearance ; the mucous membrane was here, 
as in other parts, of a purplish-red colour, marked in many places by rings 
of a white colour, and perfectly circular, and about half an inch in dia- 
meter. These rings, formed by a circle about half a line in breadth, 
included a space purple like the rest of the mucous membrane ; and in 
many places intersections of these white circles were observed ; white 
serpentine lines were also apparent in this part of the stomach. . On pla- 
cing the stomach in water, we discovered that these white circles and ser- 
pentine lines were formed by the extremities of villous processes, which 
had not a purple colour like the rest. Duodenum was also red, but the 
redness decreased gradually. One intussusception, including a portion 
of intestine six inches in length, was found in the small intestines. The 
invaginated portion of intestine was easily withdrawn from within that 
which had enclosed it, and there was not the slightest mark of inflammation 
in either. 

Observations. — This is a good example of morbid appearances exhibited 
by those fatal cases of fever which have been latterly so frequent in the 
present epidemic. We have lost nearly twenty patients, in whom the 
symptoms ran nearly the course above detailed. In all the abdomen be- 
came hard and tender about the epigastrium and hypochondria, and often 
without any premonitory symptoms indicative of the approaching danger. 
This hardness and knotted feel of the abdominal muscles, was followed by 
an appearance of general jaundice of a. bright yellow colour, accompanied by 
uneasiness and anxiety of countenance, a very quick and hurried pulse 
and coldness of extremities. Death generally took place in such cases 
within tw T enty-four hours from the appearance of the jaundice, and was 
preceded in some cases by general convulsions (as was reported", but we 
ourselves did not observe any general convulsions); in most, by spasms 
limited to the abdomen, and which obtained among the nurses the appro- 
priate name of " Twisting of the Guts," a name which agrees singularly 
with the intestinal intus-susceptions found in almost all. Before we enter 
into the subject of the pathology of this singular form of fever, we shall 
detail a few more examples of it. 

John Rochford, aged 50, was admitted into shed No. 4, with low fever; 
became convalescent after a few days without any regular crisis ; appetite 
returned, and he continued well for about six days, when he relapsed. Belly 
a little hard, and tender to the touch ; complained only of costiveness ; 
some purgative medicine was directed, which not having the desired 
effect, an oil draught was prescribed, and having operated freely, patient 
appeared much relieved at next visit ; but between 11 and 12 p.m. was 
seized with convulsions of belly, but not of extremities ; suddenly became 
jaundiced, and died next morning. The tip of his nose became of a deep 
purple colour. The friends having taken away the body, we had not an 
opportunity of examining the morbid appearances. 

Observations. — We have had several cases in which the nose became 
purple in fever, and, with one exception, they all proved fatal. When 
the purple nose is combined with general jaundice, the patient presents a 
truly frightful appearance ; this has happened in five or six instances. Some- 
times the purple colour is limited to the tip of the nose, while in other cases 
it spreads from the nose to the upper portion of the cheeks. The parts about 
to become purple assume at first a pale appearance ; this paleness gradu- 



FEVER. 185 

ally is converted into a livid leaden hue, and the part becomes quite purple, 
generally in the course of 12 or 24 hours. It is to be observed, that the 
parts thus affected preserve their natural heat until shortly before death, 
when, of course, the tip of the nose is among the first parts to grow cold. 
In the case of a girl in shed No. 2, whose nose and cheeks became pur- 
ple, this change took place more slowly than usual. At first the parts 
were observed to be covered with broad patches of a wax-like whiteness, 
somewhat elevated above the surrounding surface, which so much resem- 
bled urticaria that it was considered to approach, in its nature, to that 
eruption ; the following day, however, these spots were found to have 
become of a red colour, and on the next day the redness was converted 
into a deep purple. During the whole of this time the heat of these parts 
was not less than that of the rest of the body. She died on the following 
day. In the case of a woman in shed No. 2, in whom the tip of the nose 
and the ends of some of the toes became purple, these parts were tender 
to the touch ; this woman recovered. Leeches were applied to the tip of 
the nose, and tepid stupes or poultices kept constantly applied to the dis- 
coloured parts: a small portion of the nose separated and came away in 
the form of a slough. These facts prove that this purple colour of the 
nose and other parts, in many instances, at least, arises from a condition 
of the vascular system of these parts closely allied to inflammation. We 
possess a drawing of a patient in whom, from the effects of cold, the tops 
of the fingers became purple and excessively tender when exposed even 
to the common temperature of the wards in winter. Great relief from 
pain, and some diminution of intensity in the colour was obtained by 
keeping the fingers immersed in tepid water. This case, which was 
treated by Mr. M'Namara, had lasted for some weeks before admission, 
and yielded, but not until the lapse of a considerable time, to the employ- 
ment of tepid applications, &c. 

Patrick Mahon, aged 45, a stone-cutter, strong habit. Admitted into 
shed No. 4, labouring under fever of a typhoid character. Tongue 
loaded ; teeth covered with sordes ; abdomen hard ; tenderness of epigas- 
trium and hypochondria on pressure; complained of weakness. — Twenty 
leeches were applied to the Epigastrium, and Purgative Injections adminis- 
tered. — The following morning the skin and conjunctiva appeared slightly 
yellow. Abdomen still hard; pulse weak and quick; much debility. — - 
Was ordered some Blue Pill, and to repeat the Injections. — At the next 
visit, the yellow colour continuing, the abdomen being still hard, and the 
epigastrium tender, twenty leeches were again applied, and the former 
medicines repeated. At 4 o'clock in the evening was seized with con- 
vulsions, and died early next morning. The convulsions only appeared 
to affect the abdomen. — Body not examined. 

John Gaven, aged 22. This man's case differed in no material circum- 
stances from the preceding cases. — Dissection 20 hours after death. Body 
extremely well made, strong, and muscular. Nothing morbid in head or 
thorax, except dilatation of some bronchial tubes. — Abdomen. Five intus- 
susceptions in small instestines, without any adhesions or marks of recent 
inflammation ; other parts of the intestines considerably contracted ; 
mucous membrane of stomach, from cardiac orifice to within about two 
inches of the pylorus of a brownish-red colour. Here the mucous mem- 
brane yields readily to the back of the knife, and may be scraped off in 
a semi-fluid state ; it contains several patches of ecchymosis. The whole 



186 CLINTCAL MEDICINE. 

of the intestinal tube, with the exception of the duodenum and the lower 
half of larger intestines, has its mucous membrane of a dark red colour, 
with numerous ramifications of vessels engorged with blood. In many 
parts the mucous membrane is very soft, and almost semifluid. Liver per- 
fectly healthy; no obstruction in gall-ducts. 

Observations. — As our limits will not permit us to detail more dissec- 
tions of this truly curious and fatal form of fever, we shall merely sum up 
some of the principal points connected with its pathology. 1st. In none 
did we find inflammation of the liver, or obstruction of the gall-ducts. 
2dly. In all evident marks of inflammation were found in the mucous 
membrane of the stomach, such as redness, softness, &c. 3dly. In almost 
every instance we found one or more intus-susceptions in the small intes- 
tines. 4th. All these were without any mark of inflammation of the serous 
membrane, and the invaginated portion of the intestine could be always 
easily drawn out of the other. 5thly. In several we found effusion of a 
yellowish or amber-coloured fluid between the arachnoid and pia mater, 
at the base of the brain, and sometimes in the ventricles, but in these 
only in small quantity. 6thly. In none did we find inflammation of the 
brain or its membranes. 7thly. We have found the spleen very much 
enlarged m almost all. When the spleen in acute diseases is thus dis- 
gorged and distended, it is invariably softer than natural. In but one 
case did we find a considerable quantity of a dark red fluid in the sto- 
mach, together with a good deal of a substance resembling coffee-grounds, 
and in this case the mucous coat of the stomach was in many places of a 
very dark colour, and a slimy consistence, so that there could be but little 
doubt concerning the origin of the contained fluid, and the coffee-ground 
substance, which must have proceeded from the diseased and almost dis- 
organised mucous membrane. Such have been the principal appearances 
observed during the dissection of about fifteen fatal cases of fever com- 
bined with yellowness of the skin. The following cases will convey a 
more exact idea of the symptoms which characterise this form of fever 
than those already related, which proved too suddenly fatal to allow a 
full development of the symptoms. 

Peter Kelly, aged 28, on the 29th of December was admitted into No. 
4 fever shed, stating that for two days previously he had severe cough 
without expectoration. Pulse 110, strong; face flushed. Tongue white, 
moist; pain across forehead, and general distress; great tenderness of 
epigastrium and right hypochondrium ; costive ; thirsty ; abdomen hard : 
on examination no morbid rale was perceptible ; respiratory murmur 
natural. — 30th Dec. Vencesectio ad. §xv. Hirudinis xx. Epigastrio. 
Vesicatorum pectori. Mist, pectoralis. — 1st January, 1827. During last 
night became jaundiced ; considerable distress this morning; black stools; 
great tenderness of epigastrium and right hypochondrium ; cough very 
troublesome. Venesectio ad Jxii. Hirudines xxx. hypocondrio et epigastrio. 
Jibradantur capilli et applicetur vesicatorium verlici. Sumat omni hord 
Calomel grana duo. — 2d January. Much relieved ; skin not nearly so 
yellow ; tenderness greatly diminished ; some sweat last night. Rep. 
Pilulse. — 3d. Considerably improved ; skin nearly natural. — 4th. Mouth 
affected with mercury ; skin natural. Omittantur me die amenta. — 5th. 
Removed to convalescent ward. — 7th. Convalescence continues, having 
now 7 no complaint but slight soreness of mouth. 

Observations. — Here the yellow colour appeared about the 5th day, and 



FEVER. 1S7 

SW< at attended with much relief on the 7th day. The symptoms chiefly 
worthy oi" notice are, the violence of the febrile reaction, pain of forehead, 
great tenderness of epigastrium and right hypochondrium ; blackness of 
the stools, and hardness of the belly. We shall just now see the great 
importance of these symptoms in determining the true nature of the 
disease. 

January 14th. — Thomas Kearney, aged 38, labourer ; has been ill for 
eight days ; was first attacked with rigor and pains of loins and limbs, 
which still continue. He also complains of cough and pain of chest ; 
head first attacked on fifth day ; was taken into hospital the following i 
got some purgative, which operated powerfully. Present symptoms. Skin 
dry and hot ; eyes and skin yellow ; great pain of head ; tongue dry and 
white ; pulse 60 ; the colour of stools very dark ; epigastrium tender. — 
January 15th. Applicentur Hirudines xx. Epiga&trio, et Vesical ori urn Pec- 
tori, tt. Masses Pil. Hydrar. gr. ix. Extracti Hymciami gr. vi. M. in 
Pilulas, Ires divide. Sumai i. ter in die. Habeat Haustus Effervescent** 
cum Carbon. Ammonia, et enema Emolliens vesperi. — Jan. 16. Pain of 
chest and cough removed, and pain of epigastrium diminished since the 
application of leeches, which still continue bleeding; ordered to be stop- 
ped by the application of caustic ; tongue moist ; loaded with blackish 
paste, looking like mercurial ointment : pulse 60 ; strong ; countenance 
much improved ; stools much more natural ; yellowness nearly gone ; 
sweated much. Rep. Pil. Hydr. et Extr. Ffyosciami. — January 17th. No 
fever ; yellow colour quite gone ; many loose stools. Omittantur medi- 
camenta. — January 18th. Convalescent. 

Observations. — The state of the pulse in this case was remarkable. 
It did not exceed 60, at a time when the existence of many other 
symptoms left no doubt of the febrile and inflammatory nature of the 
complaint. 

December 30th, 1826. Easter M'Quillan, aged 33. Complains of 
general pains: has been subject to violent pains for the last three years, 
after having laboured under fever in Cork-st. Hospital ; was there also 
about four months ago, and was discharged cured. — Present state. Great 
headache ; tongue brown in centre ; pulse small and weak; great tender- 
ness of abdomen on pressure ; bowels very free ; blooded last night for 
cough and stuffing of chest ; finds herself much relieved ; blood slightly 
buffed : no separation of serum ; respiratory murmur natural ; complains 
of pain across her back. — Applicentur Hiruds xx. Epigastrio. — Dec. 31st. 
Tongue parched, furred, and brown in centre ; tenderness of epigastrium 
still remains, but much diminished ; is very slightly jaundiced ; leech- 
bites bled well ; pulse 100, regular ; great thirst ; pains of joints and small 
of back excessive, and preventing motion in bed ; breathing free ; urine 
very light coloured. — R. JfUratis Potasses jij. Decocti Hordei ft ii. 
Acid. JVUr. Di ! ut. ^i. Misce consumatur in die. — January 1st, 18:27. 
Colour more yellow ; great tenderness of epigastrium and right hypochon- 
drium : pains as before ; fever unabated. — Hab. Calomelanos gr. iij. Opii 
gr. h ter in die Mist. Camph. ^j. ter die. — January "2d. Pulse 72, weak; 
at times almost imperceptible, but regular ; respiration easy ; yellow stools 
passed under her ; belly very tense ; abdominal muscles contracted and 
hard ; tongue black and parched ; raves, but is sensible when spoken to ; 
lies oji side. Repr. P.lfltB et Misfara ; Appr. Vesicat. Hypochondria. 
Vmi Jvi. — January 3d. A good deal of cough ; raves continually; yel- 



188 CLINICAL MEDICINE. 

lowness deeper ; many yellowish stools passed under her ; debility much 
increased ; thirst continues ; tongue black and parched ; heat natural ; 
tremor ; pulse 84 ; blister rose but little ; deglutition impeded by a spasm ; 
just before visit was seized with fit, attended with spasms and rigidity of 
joints, which lasted about a minute ; feet cold. — Vini Rubri ^vj. Appr. 
Sinapismi pedibus ; Repr. Mist. Camphor. — January 4th. Sensible when 
spoken to ; puts out tongue when desired ; but at all other times raving; 
seems to suffer extremely when joints are moved ; frequent tremor and 
shuddering; rested scarcely any ; other symptoms as yesterday; some 
swelling of ankles. — Appr. Vesicatoria suris. Vini ^vi. — January 5th. 
Moaning and raving during the whole night; no vomiting; cough looser; 
slept a little this morning ; stools yellow ; tongue parched ; blisters rose 
well ; drinks abundantly; less yellowness ; no headache ; eyes suffused; 
pulse 84, scarcely to be felt, regular; no coldness of extremities; flatu- 
lence. — Repr. Vinum. — January 6th. Slept well ; no raving ; countenance 
improving ; fever much diminished in every respect. — January 7th. 
Tongue clean ; pulse 80 ; stronger than before ; a large purple spot not 
elevated occupies whole of the outside of right instep ; it is in some places 
vesicated ; appetite good ; slept well ; smaller spots on other foot ; cam- 
phorated spirit to be applied to spots. — Habeat Sulph. Quinince granum ter 
w die. — January 8th. Edges of large spot more vesicated ; whole surface 
has a redder and less purple colour ; three stools during night ; little 
sleep. — Repr. Pilules Sulph. Quininas et Vinum. — January 9th. Redness of 
right eye, not painful ; foot better. — Appr. Hirud. ii. Conjunctiva?. — Janu- 
ary 10th. Convalescent ; remained for about a week, and was discharged 
cured. 

Observations. — The symptoms of this case were very alarming ; so much 
so indeed that on the 2d and 3d of January we had little expectation of 
her recovering. At this period the involuntary discharge of stools, the 
extreme weakness of pulse, black parched tongue, general debility, rav- 
ing, tremors, spasmodic affection, which supervened when she attempted 
to swallow, and finally, the hard and knotted state of the abdominal mus- 
cles, together with a fit of general tonic spasms ; all these symptoms, com- 
bined with the yellow colour of the skin, rendered her recovery very im- 
probable. The treatment was in the commencement antiphlogistic. The 
nitre was prescribed in order to relieve the rheumatic pains ; but on the 
following day it was abandoned, and a preference given to calomel and 
opium for obvious reasons. Nitre does not act favourably in cases where 
much debility is present, or where the stomach is weak. In several of 
the cases attended with jaundice which proved fatal, the symptoms were 
very similar to those just described ; the case of M'Quillian may be looked 
on as presenting a good example of this peculiar species of fever. In her 
case, as well as in several of the fatal cases, the alvine discharges were of a 
healthy colour ; and in several of the latter the bile found in the gall-blad- 
der after death was in its properties quite natural. About one-half of the 
persons so affected, raved, betrayed great restlessness, and their counte- 
nance had a peculiar expression of anxiety ; others seemed in perfect 
possession of their intellectual faculties to the last, but at the same time 
appeared in a most nervous, irritable, and desponding state of mind. 
They could not rest for a moment tranquil, but tossed their arms about, 
and regarded their attendant with a look expressive at once of nervous 
suffering and despair. Many vomited very often ; all complained of ex- 



FEVER. 189 

treme tenderness of the epigastrium. Here we may observe, that in the 
present epidemic we have opened many bodies, in which peritoneal in- 
flammation might have been expected, judging from the extreme epigas- 
tric and abdominal tenderness during life ; and yet have found no marks 
of peritonitis whatsoever. The tenderness had been occasioned by in- 
flammation of the mucous membrane lining the stomach and small intes- 
tines. The large purple spot in the instep seemed at first of a similar 
nature with the purple colour of the nose and lips before described ; it 
proved however to be erysipelas, and ended in vesication. It differed 
from common erysipelas in its dark livid purple colour, and in having a 
well-defined abrupt boundary, and in the colour disappearing but little 
on pressure. In fact, it seemed to be as it were intermediate between 
purpura and erysipelas. The advantage of wine and stimulants towards 
the conclusion of this fever was very apparent. 

January 15, 1827. — Robert Farmer, aged 19. Has been ill five days; 
was employed in a brewery, where he was exposed to hot steam, produ- 
cing a copious perspiration, during which he drank a great quantity of 
cold beer ; was immediately seized with a violent rigor and fulness of 
head; the rigor lasted for an hour; a comparative calm ensued. The 
head, however, still continued uneasy; loss of appetite followed ; but he 
endeavoured to work for two or three days, when he was obliged to re- 
main in bed ; has been in a violent heat since, unless he gets a cold drink, 
which causes a rigor ; was admitted into hospital yesterday. Previous 
to this had taken no medicine. Present symptoms. Violent pain or 
rather fulness of head ; throbbing of temporal arteries; pulse 110 ; thorax 
free from pain ; no cough ; epigastrium and abdomen very tense ; no ten- 
derness on pressure ; skin hot, dry, and tinged with yellow ; tongue white 
and dry ; somewhat moist at edges; got some purgative which procured 
two stools, fetid and of a dark colour ; urine natural. Applicentur Hiru- 
dines xx. temporibus. R. Liquoris Acetatis Ammonice. Aquce Fontance 
singulorum giij. Tartari Emetici grunum. Syrupi gi. Misce. Sumat 
£ss. omnihord. Habt. Enema Emol/iens Vesperi. — January 16th. Leeches 
were applied at 6 p.m. ; many still bleeding; eyes and skin less yellow; 
headache less ; pulse 70 ; regular ; a slight tendency to diaphoresis. 
Repetantur Medicamenta ut heri. — January 17th. Not much headache ; 
heat and pulse natural ; much debility ; tongue clean and moist ; coun- 
tenance improved ; no appetite ; bowels free. Convalescent. — January 
26th. Left hospital the day before yesterday ; and that evening expe- 
rienced rigor, and headache. Tongue white and furred ; pulse 100 ; 
skin not very hot ; abdomen soft; bowels free; great thirst; no head- 
ache at present. Hebeat Haustus Efferves c. Carbonate Ammonice. — 
Jan. 27 ; Respirations 36. Pulse 120. Abdomen soft and natural, a 
good deal of headache ; thirst; heat of skin ; flushing of face; tongue as 
yesterday. Applicentur Hirudi ties xx. Temporibus. — January 28th. Head 
somewhat relieved ; bled all night from leech-bites ; much tenderness of 
epigastrium ; pulse 125 ; great thirst ; no vomiting ; some yellowness of 
skin, but not of eyes. R. Pilulce Hydrar. grs. ix. Extract, hyosciami grs. 
vi. Misce. Ft. Pilulce tres. Sumat unani quartis horis. — January 29th. 
Fever diminished ; was extremely wreak last night, and had great disten- 
sion of belly, with swelling and tenderness ; this attributed to taking too 
large quantities of drink ; was relieved by a large oil injection three times 
repeated. Very little yellowness to-day. Habt. Haust. Efferves. c. Car- 



190 CLINICAL MEDICINE. 

bon. Ammonia. — January 31st. Skin hot; pulse 110 ; rather weak; all 
the symptoms exacerbated since yesterday ; much thirst ; tremor ; no 
cough nor tenderness of belly ; no headache or raving ; but little sleep ; 
respirations 40 ; bowels free ; much nausea, but no vomiting. Habeat 
Haustum Oleosum. Repr. Hauslus Effervescentes c. Carb. Ammonia. — 
February 1st. Face flushed ; no headache ; a good deal of epistaxis last 
night ; dry burning heat of skin ; tongue very red at tip and edges ; 
parched in centre ; vomited last night ; much thirst ; no tenderness of epi- 
gastrium ; respirations 36 ; pulse 112; no cough ; complains at times of 
sense of distension of stomach. Habt. Mist. Carnph. cum Magnesia, gi. 
ter in die. — February 2d. No fever. Pulse 72. Convalesced slowly, 
and was dismissed cured. 

Observations. — Here the crisis of the relapse was better marked than 
that of the first attack, and occurred on the 9th day of the relapse. One 
of the most prominent features of this fever was the distended state of the 
epigastric region, in the first attack unattended by tenderness, but in the 
relapse accompanied by much epigastric tenderness. It is probable, there- 
fore, that the distended state of the epigastric region proceeded in both 
instances from the same cause, namely, inflammation of the mucous mem- 
brane of the stomach. We have already seen that this inflammation may, 
and generally does produce very great tenderness ; this case, however, 
seems to prove that inflammation of the mucous membrane of the stomach 
may occasionally exist without producing tenderness. We have found 
both the extract and tincture of Hyosciamus extremely useful in abating 
irritability and procuring sleep in the advanced stages of fever. In the 
fevers attended with jaundice we were induced to combine it with mer- 
curials, from observing the frequent occurrence of intus-susception in the 
fatal cases — still bearing in mind, that means calculated to abate the in- 
flammation of the stomach and intestines, by lessening the cause, would 
strike at the root of the spasm, and thus prove the best antispasmodics. 
This plan has been successful in several instances, but in the majority of 
the yellow cases, we regret to say, that the progress of the disease was so 
sudden, mostly terminating in 24 hours after the appearance of the jaundice, 
that all our efforts proved ineffectual. In our next report will be found 
the history of the dissection of several of those cases which have occurred 
since the beginning of February. It is not to be supposed that the pre- 
sent report affords specimens of all the varieties of fever treated during 
the time it embraces — we have omitted to detail any but those calculated 
to convey an accurate idea of the general character of the epidemic and 
its peculiarities, reserving for a future period an account of the more ordi- 
nary forms of maculated and typhous fever, which were not unfrequently 
observed. At present we shall conclude with some remarks on that form 
of fever which was accompanied by jaundice. Cases of probably a similar 
nature have been observed by Dr. Cheyne and others in former epidemics, 
but in no other epidemic were they so frequent or so fatal in this city. 
Those who are familiar with the symptoms and morbid appearances ob- 
served in the yellow fever of America, the West Indies, and of Spain, 
will at once perceive many striking points of resemblance between yellow 
fever, properly so called, and that variety of fever we have described. 
In both the yellow colour depends upon the presence of bile, and in both 
the absorption of bile into the system, seem independent of hepatic 
inflammation or obstruction in the biliary ducts. We are aware that 



FEVER. 191 

Tommasini, in his excellent work upon the fever which occurred at Leg- 
horn in 1804,* proves that the liver is inflamed not unfrequently in yellow 
fever, and he supposes that it is inflamed in all cases, arguing that where 
no very visible or external marks of hepatic inflammation have been ob- 
served, that still inflammation may have existed in the internal parts of 
the liver, attacking chiefly its vascular system and the pori biliarii. 
{Page 315.) As, however, no such inflammation, to our knowledge, has 
been detected in those cases of yellow fever which present an apparently 
healthy state of the liver, and as the most accurate descriptions of the 
morbid anatomy of yellow fever with which we are acquainted,! report a 
healthy state of the liver in the majority of cases, we must, for the present 
at least, consider the jaundice of yellow fever as independent of hepatitis. 
An inflamed state of the mucous membrane of the stomach, often amounting 
to its absolute disorganization, is the most constant and the most essential 
morbid appearance in yellow fever: — a similar state of the duodenum is 
likewise frequent ; now in both these respects our cases agree with yellow 
fever, except indeed that in the latter the disorganization of the mucous 
membrane is greater; still, however, this is only a difference in do<rree ; and 
in one of our cases, we have seen that the disorganization of the mucous 
membrane was fully equal to that described in yellow fever attended with the 
black vomit ; and in that case the stomach contained a matter very similar 
to, if not absolutely identical with, the black vomit. We should recollect 
also, in comparing these two forms of disease together, that in many 
instances of yellow fever there is no black vomit, and the inflammation 
has in such persons been found to have attained a degree not greater than 
was observed in our cases. The tenderness of the epigastrium, so promi- 
nent a feature in yellow fever, occurred in all our patients ; and if space 
permitted, we could point out many other circumstances of similarity 
between these two forms of fever. It may appear to many ridiculous to 
maintain a similarity between these cases and yellow fever, a disease of 
warmer climates, and which commits such fearful ravages wherever it 
appears. We need, however, only refer to the works of Tommasini, of 
Bancroft, and Dr. James Johnson, which contain ample proofs that eve i 
in the warmest latitudes epidemics of yellow fever are always mixed with 
fevers of a bilious character, but of a milder type ; a circumstance which 
renders it highly probable, that were such an epidemic influence at any 
time, from a particular combination of circumstances, to spread to tempe- 
rate latitudes, the reverse would happen, and this influence would then 
produce an epidemic of a bilious or gastric character, with comparatively 
few cases approaching in violence to yellow fever. Tommasini and the 
best modern pathologists consider it as now placed beyond all doubt, 
that yellow fever cannot be considered as a specific disease, but merely 
as the maximum of bilious or gastric fevers. In proportion to the warmth 
of the climate these fevers increase in intensity. Thus, in Cadiz and 
Gibraltar we need not be surprised at the occasional appearance of the 
yellow fever, approaching in violence to that of the southern parts of 
North America and the West Indies. At Leghorn the resemblance, 
although still striking, was not so perfect ; and again, in the bilious epi- 
demics of France, Holland, and Germany, the difference, as to intensity, 

* Sulla Febbre di Livorno, e sulla Febbre Gialla, &c. 
. f See Lawrence's very accurate Dissections of Subjects of Dead of the Yellow Fever, made 
at New Orleans during the years 1 8 17- IS- 1 9.— Philadelphia Journal, Vol. I. New Series. 



192 CLINICAL MEDICINE. 

is still greater (Tommasini, 81, 82, 83), but still the disease, in its essen- 
tial characters, remains the same in all and the same symptoms, and the 
same morbid lesions are found ; — they differ only in degree. Hitherto 
we have not made any remarks on the frequent occurrence of spasmodic 
action to the intestines, as proved by the intus-susceptions so constantly 
observed in our cases, a circumstance , we believe, peculiar to those cases, 
for we have not met with any account of a similar occurrence in other epi- 
demics. How far such spasms, either by directly causing a temporary 
constriction of the ductus communis choledochus where it enters the intes- 
tine, or by extending to that duct itself, may have contributed to obstruct 
the passage of the bile and thus produce the jaundice, is a question worthy 
of consideration. 

On looking over my papers I found the following notes of a clinical 
lecture delivered at the Meath Hospital in the year 1827. As they have 
especial reference to the subject under consideration, I shall make no 
apology for introducing them in this place, merely premising that they are 
printed as they stand in the manuscript, and must be regarded as the 
heads of a lecture, and not as conveying all that 1 may have said on the 
occasion. 

" In fact there is not so much difference between the diseases of Ireland 
and warmer countries, as has been imagined. They differ, it is true, as 
to their degrees, but not as to their pathology. 

It was an opinion long ago advanced by Dr. Stokes, senior, that almost 
all fevers pass into each other — thus intermittent may become continued, 
and typhus fever, perhaps, but an inferior grade of plague. Be this 
as it may, each particular epidemic has a grade peculiar to itself. The 
present fever in Dublin, the most worthy of notice we have ever had here 
— it strongly proves that our diseases differ only in degree from those of 
warmer latitudes. We have had numerous cases which in their symp- 
toms, and their morbid anatomy, agree essentially with the yellow fever. 
This is an opinion I have never before expressed, as I was unwilling to 
do so until after careful examination and study. As it is a subject of 
novelty and great importance, let us for a moment consider the points of 
resemblance. Passing events always make a deep impression when the 
attention is properly directed towards them. I stand here to improve you, 
if I can, in the pathology and practice of physic, and scruple not to 
deviate a little from my course, if that deviation is calculated to awaken 
your attention to an important subject. 

1st. In both, patients become yellow from absorption of bile into the 
system ; but observe, in epidemics of yellow fever, it never happens that 
all, or even most of the cases turn yellow. 

2d. These yellow cases are here equally fatal. 

3d. Tenderness of epigastrium, and vomiting in both. 

4th. The strongest who die. 

5th. Jaundice does not depend on hepatitis in either. 

6th. Nor on any permanent obstruction in gall-ducts. 

7th. In both seat of disease is a violent inflammation of mucous mem- 
brane of stomach and duodenum ; dark purple, soft, semifluid. 

8th. Black vomit in true yellow fever consists of a sanguineous fluid, 
mixed with vitiated secretion of stomach and blood forms coffee-grounds. 
This black vomit we found in one of our patients' stomach. 

9th. Enlarged state of spleen. 



FEVER. 193 

What is the cause of yellowness in yellow fever? Absorption of bile. 
But what causes bile to be impeded — there is no obstruction in the liver 
itself, as in hepatitis, or in ducts, as in gall-stones, &c. ? 

It has been ascribed to vomiting, but this is not the true cause. 

1st. Jt has appeared in yellow fever when there was no vomiting. 

2d. We do not find that constant vomiting, as in sea-sickness, how- 
ever long it lasts, produces jaundice. On the contrary, vomiting often 
used as a cure for jaundice, as it produces a greater flow of bile from 
ducts. 

The opinion of Broussais seems most correct, that the yellow colour 
depends solely on the violent irritation of the duodenum, which is propa- 
gated to the secreting organ of the liver. 

This is nearest the truth, but still does not seem quite satisfactory. If 
the irritation or inflammation of the duodenum was propagated to liver, 
we must expect to find that organ inflamed. However no such thing in 
either case. 

Now our dissections have, I think, thrown a new light on the subject, 
and shown the true nature of the obstruction to the flow of the bile which 
exists in this complaint. In almost all the cases of fever with jaundice 
which have proved fatal, we have found one or more intussusceptions of 
the small intestines, without any inflammation of the invaginated part 
(serous membrane). Now jet us consider what aid we receive from the 
finding of these intus-susceptions, towards explaining the origin of the 
jaundice ; but, 1st, what is the origin of spasm ? Inflammation of mucous 
membrane of duodenum, .and small intestines, and stomach. In dysentery 
we find evident spasm of large intestines from inflammation, tenesmus, &c. 
Well, then, having rendered it probable that spasm exists, depending on 
inflammation, how does this bear on jaundice? We have all heard of 
spasm of the gall-ducts causing jaundice, and best treated by opium, 
baths, &c. 

We must suppose spasm in the duodenum capable of being propagated 
to ducts, or of directly shutting duct. 

This spasm constantly occurring, produces every time it takes place 
a constriction of duct, while quantity of bile is not diminished, the con- 
sequence of which is jaundice. 

Having thus proved a remarkable coincidence between these diseases, 
if not their absolute identity, let us see how their treatment agrees. We 
have found by experience that the only treatment which will serve patients 
in these cases, is that which has been adopted in yellow fever by the most 
enlightened and experienced physicians — depletion by lancet and leeches, 
and large doses of calomel, blue pill, hyoscyamus, fce." 

At the time the above lecture was delivered, I, in common with others, 
believed that all efferent ducts possessed a vital contractility, because we 
had observed many phenomena which could only be explained on this 
supposition. Since then, physiologists have applied themselves to the 
solution of this question, and it is now generally admitted that these 
ducts do possess the power of contraction, for which they are indebted 
to a muscular coat. I shall here quote from the highest authority we 
possess : 

14 The efferent ducts of glands are lined by a mucous membrane, which 
has on its exterior an extremely thin layer of muscular substance. The 
existence of muscular fibres cannot, it is true, be demonstrated anatomi- 
14 



194 CLINICAL MEDICINE. 

cally,* but physiological observations place it beyond dispute. The 
efferent ducts of most glands have the power of contracting when irri- 
tated. The contractile power of the ductus choledochus in birds was 
known to Rudolphi. By irritating mechanically, or by galvanism, the 
ductus choledochus of a bird just dead, I have frequently produced a very 
strong contraction of it, which continued some minutes, after which the 
duct resumed its previous state. I have often excited strong local con- 
traction of the ureters likewise, both in birds and in rabbits, by the appli- 
cation of a powerful galvanic stimulus. Tiedemann also has seen motions 
in the vas deferens of a horse, ensue on the application of a stimulus. It 
appears, indeed, that periodic vermicular motions are performed by the 
efferent ducts, at least by the ductus choledochus in birds ; for once in a 
bird just killed, I observed contractions of the duct regularly in pauses of 
several minutes : the tube dilating again in the intervals. It was here 
remarkable, that the contractions took place in an ascending direction, 
namely, from the intestine towards the liver ; which seems to throw some 
light on the mode in which the bile at certain times, instead of being 
expelled into the intestines, is retained and driven into the diverticulum 
of the duct, namely, the gall-bladder, the complete closure of the duct 
contributing perhaps to this effect. 

" The discharge of the bile from the gall-bladder during digestion results 
probably from the mere pressure of the surrounding parts, and the action 
of the abdominal muscles, while the mouth of the duct is open: for I doubt 
if the gall-bladder is contractile : I could produce no contraction of it in 
mammalia and birds, even with the most powerful stimulus of a galvanic 
battery ; and in this respect it differs from the other diverticula of efferent 
ducts, namely the urinary bladder, and the vesiculae seminales, which it 
resembles in all its characters. 

" Dr. G. H. Meyer however states, that by means of a galvanic battery 
of fifty pairs of plates, he has caused the gall-bladder of an ox to contract 
so as to diminish its capacity one-fourth. 

u How far the contractility of the ducts may contribute to the frequently 
sudden expulsion of the saliva and tears, is a question which I mention 
merely, as requiring further investigation. I may, in conclusion, remark, 
that since the contractility of the ducts of glands is proved experimentally 
the spasm of these parts, spoken of by physicians, ceases to be a mere hypo- 
thesis." — M tiller's Physiology, page 520. 

Before I conclude this subject, it may be well briefly to consider how 
far the Dublin fever of 1826-7, agreed with that since observed at Gib- 
raltar, by Louis. 

The prominent symptoms in the yellow fever of Gibraltar were, flush- 
ing of the face, headache, suffusion and pain in the eyes, pains in the limbs, 
thirst, loss of appetite; it was rare that the patient complained of any pain 
in the epigastrium at first, but this generally came on 15 or ]6 hours from 
the commencement of the disease, and was then inconsiderable, and very few 
patients complained of severe or acute pain. The abdomen preserved its 
form, was supple and indolent, except in the epigastric region. The yel- 
low appearance of the skin did not come on till late in the disease, and 

* " This appears to have been done, however, by Dr. G. H. Meyer (Diss, inaug. de musculis 
in duct. eff. Glandul. Berol, 1837). He describes the course which the fibres take in the dif- 
ferent layers of the muscular coat of the ureters of the horse and gall-bladder of the ox." — 
MUller's Physiology, page 250. 



FEVER. 195 

was seldom very intense, and it was about the same period that the vomit- 
ing and dejections assumed their peculiar character; the dejections were 
blackish or bluish, and the matter vomited, from being of a yellow colour, 
became black or brown. The reader will at once perceive that the symp- 
toms which attended the cases of yellow fever we witnessed in 1826, in- 
dicated a more intense disease of the abdominal viscera — in all there was 
tenderness over the epigastrium, which in some was excessive — black vo- 
miting did not occur in all, but even in the yellow fever of tropical coun- 
tries it is not constant, but the symptom which presented the greatest dif- 
ference in the two epidemics was the yellowness of the skin, which in the 
fever of Gibraltar came on towards the latter period of the disease, and 
was seldom very intense, but in our fever it came on suddenly, immediately 
after the tenderness of the epigastrium was complained of, and was in all 
very intense. This shows that whatever lesion produced the yellowness 
in the Gibraltar fever, was either different in kind, or in degree, from that 
which caused it in ours, and I think we cannot doubt but that it was here 
produced by spasm of the ducts leading from the liver and gall-bladder. 

It is well known to pathologists since the time of Broussais, that jaun- 
dice is as frequently produced by duodenitis as hepatitis if not more so — 
but I do not think that the explanation he gives is applicable to our cases. 
He concludes that when the mucous surface of the duodenum is thrown 
into a state of excitement, we may have a consequent affection of the liver, 
for the duodenum bears the same relation to the liver as the mouth does 
to the parotid gland, and we know that an irritation of the orifice of the 
ducts leading from this and the other salivary glands is immediately fol- 
lowed by an increased flow of their secretions. But our dissections have 
shown that the small intestines were affected not only by inflammation, but 
were acted upon by violent spasms, producing invaginations of different 
portions of the canal ; and there can be no doubt that the ducts (possess- 
ing such considerable vital contractility) participated in these spasms, and 
thus prevented the flow of bile into the duodenum, as effectually as if they 
were tied by a ligature, or their canals obstructed by calculi, and this ex- 
planation obtained great support from the fact, that the jaundice came on 
suddenly, in most of the cases, and was always preceded, or accompanied, 
by violent and convulsive contractions of the abdominal muscles and intes- 
tines. 

There is another point to which I am anxious to direct attention. 

Yellow fever has only been once observed in this country; and then it 
occurred in the course of an epidemic of continued fever, whose type was 
a severe and very fatal form of gastro-duodenitis. Does not this circum- 
stance tend to confirm the opinion of Tommasini and others, that yellow 
fever is but a more severe form of the gastric variety of typhus? The 
appearance of the liver described by Louis has not been noticed by any 
other pathologists, and cannot be considered the essential anatomical cha- 
racter of yellow fever generally; for we read that Rush and Lawrence, the 
learned writers on the yellow fever of America, seldom found the jaundice 
connected with liver disease, but that in all cases there was inflammation 
of the digestive surface: and in the late epidemic of yellow fever, which 
prevailed in Martinique from 1839 to 1841, M. Rufz states, that he ob- 
served the yellow appearance of the liver, described by Louis, only in two 
instances, and that this organ, like the rest of the solid viscera, was very 
often gorged with blood. In the Martinique epidemic, the principal pa- 



196 CLINICAL MEDICINE. 

thological appearances were the following: — " The stomach contained 
matter of a black colour, generally in great quantity, and the mucous mem- 
brane was coloured by this substance ; but when the contents were removed, 
and the mucous membrane washed, he found that it presented a beautiful 
rose-coloured hue, extending all over its surface, and not produced by dis- 
tinct vascular arborizations. In the midst of this redness, he observed 
several round and distinct spots, produced by the effusion of small quan- 
tities of dark-coloured blood, having all the appearance of spots of purpura 
hcemorrhagica. The mucous membrane was neither thickened nor softened, 
but was evidently much more easily detached than in the natural condi- 
tion. The small intestines contained a greyish white matter, particularly 
the jejunum; the mucous membrane presented precisely the same appear- 
ance as the stomach, but the hemorrhagic spots were more numerous and 
much larger. The glands of Brunner were in a few cases enlarged to the 
size of millet-seeds — but in no instance were the glands of Peyer in the 
least altered." 

During the prevalence of the yellow fever in 1826-7, a captain of a 
West-Indian vessel was admitted into hospital with the disease. He had 
had yellow fever in Jamaica, and stated positively that he was, when 
under our care, affected in precisely the same manner as he had been in 
Jamaica ; and he also remarked that the other patients seemed to labour 
under exactly the same kind of fever as he had then witnessed. 



LECTURE XIX. 



Intermittent fever — Account of the Russian intermittent fever — Case of tertiana soporosa — 
Treatment of intermittent fever. 

I will now read for you the notes of a case of intermittent fever, taken by 
Mr. Power : — 

" Mary Gannon, aged 44, was attacked by intermittent fever about the 
middle of September last. The paroxysms occurred twice every day, one 
in the morning, the other in the afternoon, for the space of ten days, after 
which, owing to medical treatment, the evening one disappeared. On 
the 10th of October she was admitted into the Meath Hospital, and was 
placed under the care of Dr. Stokes, who prescribed small doses of sul- 
phate of quinine, under the use of which the fit became tertian, but soon 
afterwards returned to the quotidian form. On the 1st of November she 
became a patient of Dr. Graves, and was put on large doses of the sul- 
phate of quinine. On the 7th of the same month, the fit again assumed 
the tertian form, in which state it continued until the 17th, although the 
dose of quinine had been increased to a scruple and a half in the day. 
She was then blooded to ixviij., by which the duration of the paroxysm 
was lessened, and the interval between it and the succeeding one increased 
by twelve hours. She was again blooded, and the fit became quartan. 
Venesection was employed for three times more, but without any other 
sensible effect than a curtailment of the duration of the existing paroxysm. 
Her strength now became reduced, and she was ordered to take four 
drops of the liquor arsenicalis in half an ounce of mint-water, three times 
a-day. Since she commenced taking the arsenic, the violence of the 



FEVER. 197 

paroxysms has been gradually subsiding, and strength and appetite are 
returning ; at present, the fit presents scarcely any other characters than 
those of a slight shivering." 

Let me make a few remarks on this case. In the first place you should 
look to the definition of a quartan ague. According to Cullen, this con- 
sists of " paroxysmi similes intervallo septuaginta duarum circiter horarum ; 
accessionibus pome i'id/'anis," that is to say, the attacks must be similar, 
there must be an interval of 72 hours between them, and the fit is to come 
on in the afternoon. Let us examine how far the characters of the present 
case coincide with this definition. Latterly, she had seven attacks with 
a precise interval of 72 hours ; in the next place the attacks were similar ; 
so far so good ; but the accessions of her paroxysms were in the forenoon 
and not in the afternoon, for they generally came on about eight o'clock 
in the morning, and in this respect accommodated themselves to our con- 
venience, for we could be here to witness them. It is very true that we 
generally find the paroxysm of quotidian in the morning, of tertian in the 
middle of the day, and of quartan in the evening, and also that one may 
pass into the other, but to this I do not attach much importance. Here 
the disease evidently terminated by becoming quartan. A question arises 
as to what was the nature of the fever in the commencement? Was it any 
variety of quartan ? that is, was it quartan disguised under the type of any 
other species of intermittent ? In the beginning, she had two paroxysms 
every day, constituting what has been termed the quotidiana duplex, a 
disease which is common enough, though it has not been noticed by Cul- 
len in his Nosology. The nearest approach which the first form of our 
case makes to the acknowledged quartan of authors, is to the quartana 
triplex, where we have the fit coming on three times a-day, with every 
fourth paroxysm similar. But you perceive, plainly, that Gannon's fever, 
in its first form, is not reconcileable to any known type of quartan ague. 
Now, what was the effect of the remedies employed ? First to make it 
assume the form of a simple quotidian, and as a still further improvement, 
resolved this into a tertian. Here we have an argument against the sup- 
position of a concealed quartan, for an interval of 48 cannot, by doubling, 
be converted into an interval of 72. But the effect of remedies, never- 
theless, produced this antinosological conversion, for the first bleeding in 
the cold stage made an addition of 12 hours to the tertian interval ; and 
a second bleeding added another two hours, and then we had the quo- 
tidian interval completed. This was indeed a bit-and-bit reform of a 
double quotidian into a simple quartan. Let us review the length of the 
intervals in a series of numbers. First ; it was 12 hours for the space of 
10 days; next, 24 hours for several days; then, 48 hours for several 
days ; again, 24 hours for several days, then 48 for several days, then 60 
for one day, and, lastly, 72 for seven days. From this, I think, we may 
conclude, that the unit from which we ought to set out in calculating in- 
tervals should be twelve hours between the accession of one attack and 
the accession of the next. This is the atom on which all our computa- 
tions must be founded, for its multiples include all the varieties of inter- 
mittent fever. It would appear, that instances, where the fit comes on 
earlier than was expected, or is postponed beyond the customary period, 
would go to invalidate what I have mentioned. Such cases, however, I 
look upon as only transition stages to more permanent varieties. In many 
cases of quotidian, it has been observed by nosologists, that every second 



198 CLINICAL MEDICINE. 

fit is more severe, and hence they have termed this form the tertiana 
duplex. The chief argument in support of this opinion of quotidians 
becoming tertians is, that under the salutary influence of our remedies, 
they become tertians before they cease altogether. In answer to this, it 
may be observed, first, that this is not always the case ; secondly, when 
it does take place, it is because the days of the least severe fits are of 
course those on which they soonest cease, in consequence of the exhibi- 
tion of bark, or sulphate of quinine, for it often happens that these medi- 
cines do not remove the aguish fits entirely and at once, but gradually, 
and, as it were, by wearing down the paroxysms. Thus, then, a quotidian, 
such as we have described, must, if gradually cured, before a complete 
cure is effected, observe the tertian interval ; but still it is not a true ter- 
tian at any period of its duration. Hectic fever, notoriously, has inter- 
vals of 12 hours, and it may be observed, that many circumstances cor- 
roborate the opinion, that in naming and classifying diseases, it is more 
consonant with the laws that regulate the diurnal revolutions of the ani- 
mal economy, to use, as our period, 12 hours, whose multiples give rise 
to the different intervals of agues, than to assume 24 hours, as the term 
from which we are to commence our calculations. Thus the state of the 
pulse, according to the late laborious investigations of Nick, have shown, 
that a regular revolution, as to its frequency, takes place every twelve 
hours, and the same result has been made with regard to the intensity of 
the respiratory process. We all know that there is a considerable differ- 
ence between the nervous and calorific powers of the body during the 
twelve hours we spend in active employment and awake, and those which 
are chiefly passed in tranquillity and repose. 

As the average period of day and night respectively is twelve hours, 
in the same manner equivalent spaces of time seem to be destined for the 
successive and alternating revolutions of the living system. It would be 
extremely interesting to consider what influence their adoption might have 
in our calculations concerning the crisis of continued fevers. We would 
not then count three days and a half, but seven half-days ; we would not 
say seven days, but fourteen half-days. If this method were adopted, 
many of the apparent anomalous critical effects and critical terminations, 
in continued fevers, would, I have no doubt, become strictly conformable 
to some regular law of periodicity. To arrive at a knowledge of this law 
would be of the greatest importance, and would tend much to render our 
knowledge of fevers more accurate, and our treatment more efficacious. 
Those who entirely deny the critical period must be either very superficial 
observers or very indifferent practitioners. In private practice, where 
the precise commencement of the attack can be ascertained, a crisis, or 
an obvious attempt at a crisis, takes place, often on the reputed critical 
days, occasionally on others; and if the treatment be judicious, it seldom 
happens that a fever terminates without either. Within the last year T 
have seen two cases, in which decided and perfect crisis took place on 
the 42d day. In another case a salutary crisis took place on the 35th 
day. The first of these cases I saw along with Dr. Stokes ; the second, 
with Dr. Plant ; the third, with Mr. Rumley. In another case, which I 
attended with Mr. Kirby, there was an obvious but unsuccessful effort at 
crisis on the 7th, 14th, 21st, 28th, and 35th days. 

I must admit that I have seen perfect crisis on days not reputed criti- 
cal ; but 1 am convinced, that if the method of counting by half- days and 



FEVER. 199 

not by days were adopted, the exceptions to the occurrence of crisis would 
be much less numerous. The nature of crisis has never, I think, been 
truly explained. To me it appears evident, that all the phenomena which 
attend this curious change prove, that when a continued fever terminates 
by crisis, it is by being converted into a fever of a new type and shorter 
duration. Well-marked crisis comes on almost like a fit of the ague ; it 
is ushered in by great collapse, coldness, and even sometimes by rigor. 
This is succeeded by a hot fit, and that again by a sweating stage, copious 
deposition in the urine, &c, and then the patient is found free from fever. 
Is it not probable, therefore, that the crisis is not merely the termination 
of the former fever, but a new fever, as it were, superadded to it for the 
purpose of exciting a change in the system, attended by such a powerful 
action of another kind, that the former chain of morbid actions is broken, 
and the tendency of the new fever to terminate in health is thereby allowed 
to prevail. 

To many, I am aware, what I have said may seem fanciful, but to a 
close and candid observer of nature this hypothesis may not appear alto- 
gether unfounded. 

I shall not detain you, gentlemen, in making any remarks on the treat- 
ment pursued in Gannon's case. You have seen how the sulphate of 
quinine changed the type of the fever, and you observed how completely 
the liquor arsenica/is succeeded in removing the disease, after other re- 
medies had failed. It is to be recollected, however, that considerable 
advantage was derived from venesection in the cold stage, and it is pro- 
bable that this treatment by the lancet was a useful preparation for that 
by arsenic. It has been supposed that bleeding, during the cold stage of 
ague, produces a favourable effect, in consequence of its relieving the 
internal sanguineous congestion. This hypothesis, however, does not 
appear well founded, for the utility of venesection is by no means con- 
fined to those cases of intermittent fever, whose cold stages are attended 
by an evident diminution in the external circulation, denoted by a shrunk 
countenance, cold and pointed nose, and a pale corrugated skin. In such 
cases it is very reasonable to conclude, that the internal organs must 
labour under sanguineous congestion, as long as the quantity of blood in 
the periphery of the body is diminished ; but this obvious deviation from 
the proper balance of the circulation is not observable in every case ; and 
in that related above, the temperature of the external parts was increased 
at the very moment that the violence of the rigor was greatest, while at 
the same time the extremities, face, and general surface of the skin ap- 
peared to enjoy a more than usually abundant and active circulation. 
We must, therefore, refer the benefit derived from the venesection to some 
other cause, most probably its energetic action on the nervous system ; it 
is to this we must attribute its effects in stopping the rigor and lengthen- 
ing the intermissions. 

That the rigor of ague is an affection chiefly depending on the nervous 
system may be proved by many circumstances, but by none more strongly 
than by the following fact, quoted from a collection of Notices of Russia, 
published in the United Service Journal for January, 1833 : — 

" In Kasan these fevers are quotidian or tertian, very rarely quartan, 
and they differ from the agues of other countries in this respect, that the 
patient experiences scarcely any shivering, but feels a violent twitching 
in the spine, which is soon followed by excessive heat and violent head- 



200 CLINICAL MEDICINE. 

ache, during which the pulse beats like a hammer. For this fever, the 
Russian physicians resort to no other remedy but bark." 

The following description of the Russian province, so fertile in ague, 
is so striking that I shall take the liberty of reading it to you : — 

" The summer in this country is further remarkable, inasmuch as from 
the end of May to the beginning of September, no rain falls, and thunder- 
storms are extremely rare. This phenomenon is doubtless owing to the 
flatness of the country. For five hundred miles and more, around Perm 
and Kasan, there is not a hill of any consequence, and the whole tract 
from Kiew to Ural, for a breadth of five hundred miles, may be called a 
plain, only here and there interrupted by ranges of gentle hills. The ex- 
traordinary fertility, especially of the government of Kasan, is occasioned 
by the inundation of the Wolga, which overflows annually at particular 
seasons, as regularly as the Nile in Egypt, and converts the whole coun- 
try, to the distance often miles or more from its bed, for five or six weeks, 
into an immense sea. These inundations of the Wolga, and the other 
large rivers, the Witjatka, the Kama, the Kinel, the Irgis, &c, which 
discharge themselves into the Wolga, render the countries through which 
they flow at once lively and fertile. At such seasons you may sail, either 
for pleasure or upon business, in large two-masted vessels, carrying from 
six to ten guns, over pastures and corn-fields, to the neighbouring towns, 
which on this account, are all situated upon heights ; and when the waters 
have withdrawn into their accustomed channels, the ground forsaken by 
them is covered, often a yard deep, with a fertilising mud, in which, 
during the hot season, all vegetables grow rapidly and vigorously as in a 
hot-house. At the same time pools are left behind in the low grounds, 
where the water stagnates for several months, becomes putrid and gene- 
rates malignant fevers in the months of July and August in these other- 
wise healthy countries. The government of Ufa, particularly, is visited 
about that time by an intermittent fever, which attacks the patients every 
seventh day only, but is so violent, that it generally proves fatal." 

If this account be correct, and indeed there can be little doubt of its 
accuracy, a new species of ague must be established, and to the quotidian, 
tertian, and quartan, must be added a fourth type, whose attacks return 
every seventh day. 

In Ireland we seldom meet with cases of ague with paroxysms so vio- 
lent as to endanger the patient's life. I lately saw, however, a case of 
this nature. I was sent for in a great hurry to visit a gentleman residing 
in the neighbourhood of Donnybrook ; he had slept well until four o'clock 
in the morning, when he was awakened by a general feeling of malaise, 
shortly after which he complained of chilliness, some nausea, and head- 
ache. After these symptoms had continued about an hour, his skin be- 
came extremely hot, the pain in the head intense, and drowsiness was 
complained of, which soon ended in perfect coma, with deep snoring and 
insensibility; in fact, he appeared to be labouring under a violent apo- 
plectic fit. He seemed to derive much advantage from bleeding and 
other remedies, and to my surprise was perfectly well when I visited him 
in the evening. The day but one after, at the same hour, the very same 
symptoms returned, and were removed by the same remedies. I must 
conless that I could not explain, in a satisfactory manner, the perfect 
freedom from all cerebral and paralytic symptoms, after two such violent 
attacks of apoplexy ; but when a third attack came on, I then saw that it 



BRONCHITIS. 201 

was a case of the tertiamt soporosa of nosologists, and I prevented the 
return of the fits by the immediate exhibition of large doses of sulphate of 
quinine. 

Numerous remedies have been recommended for the cure of intermit- 
tents ; but, I believe, those already mentioned, with salicine, piperine, 
and ilicine, and venesection, in or before the cold fit, are most efficacious. 



LECTURE XX. 

Causes of catarrhal affections of the bronchial tubes — On the rales produced by bronchitis — 
Remarkable disproportion between the frequency of the pulse and the respiration — Use of 
emetics and chalybeates in chronic bronchitis — Symptoms that contraindtcafe chalybeates — 
Case of asthma, and treatment — ^t. John Long's liniment — Case of chronic cough — Re- 
marks on bronchial secretion — Expectoration never performed during sleep — Ethels of 
catarrhal attack frequently recurring — Account of remedies employed — Cir*at power of nitrate 
of potash, combined with tartar emetic in subduing inflammation — Observations on the 
secretion of air from the mucous membrane of the intestines in certain pulmonary affections 
— Kfficacy of sulphur in chronic bronchitis — Senaatton of tickling which precede* cough — 
Cough from worms — Hysteric cough — Pulmonary irritation from a syphilitic taint— Pulmo- 
nary irritation connected with a gouty diathesis; with a scorbutic habit; with scrofula. 

Allow me to direct your attention to-day to the case of J. Jowson in the 
chronic ward, labouring under an attack of exasperated chronic bron- 
chitis — a disease which derives its chief importance from the circum- 
stance of being exceedingly common. There is no morbid affection of 
the system more frequent or more general than chronic bronchitis; it is 
of every day occurrence in dispensary practice; it is one of those cases 
which you will be constantly called on to treat; and hence the study of its 
nature and treatment has strong claims on your attention. 

Bronchitis is an affection which generally arises from impressions made 
by cold, either on the skin or on the mucous membrane of the lung. I 
think it extremely probable that, when a person gets a catarrhal affection 
from exposure to cold, it is not always in consequence of an impression 
made on some part of the cutaneous surface. Indeed, it appears reason- 
able to believe that an attack of bronchial inflammation may be equally the 
result of an impression made directly on the mucous lining of the lung; 
and that a person exposed to sudden change of temperature, as in passing 
from a heated room into the cold air, may get inflammation of the mucous 
membrane of the bronchial tubes, for the same reasons that, under similar 
circumstances, inflammation may be generated in the mucous membrane 
of the eye, giving rise to conjunctivitis. We know well that one of the 
most common causes of inflammation of the conjunctiva, is the sudden ex- 
posure of the eye to cold sharp air, after it has been for some time sub- 
mitted to the relaxing influences of strong heat and light; and there is no 
reason why the same rapid change of temperature, under similar predis- 
posing causes, should not originate disease in the mucous membrane of 
the bronchial tubes. It is true, indeed, that nature has taken especial 
pains to maintain an equable temperature in the air admitted into the chest 
at each respiration; the passage of this air through the mouth, nose, and 
pharynx, where it is warmed by the contact of an extensive raucous sur- 
face, and the small proportion which it bears to the residual air remaining 
in the lungs after an ordinary expiration, are circumstances that must 



20*2 CLINICAL MEDICINE. 

powerfully counteract the low temperature of air inspired in very cold 
weather. Still a considerable difference of temperature must exist between 
the inspired and expired air, and consequently the air-passages are exposed, 
more than any other tissue of the body, to successive and rapid alternations, 
which never cease from infancy to old age. Nature has, of course, wisely 
accommodated the vitality of the bronchial mucous membrane to the cir- 
cumstances in which it is placed, and the force of a never-ceasing habit 
still further enables it to sustain rapid vicissitudes of temperature with im- 
punity. In this it is probably equalled by the surface of the eyeball, which, 
alternately covered, warmed, and moistened by the eyelids during the act 
of winking, and exposed to the cold of the air, increased by a rapid eva- 
poration from its own surface while the eye is open, must, indeed, undergo 
rapid variations of temperature, and yet it is never frost-bitten. 

When inflammation has fastened on the mucous membrane of the air- 
passages, it makes a vast difference as to the part on which it fixes. The 
air-passages commence with the larynx, and terminate with the ultimate 
ramifications of the bronchial tubes. If the disease settles at the entrance 
of the air-passages, and forms laryngitis, the case becomes a very serious 
one, laryngitis being in the infant, and sometimes also in the adult, at- 
tended with dangerous and even fatal symptoms. If the trachea should 
happen to be the part on which the disease falls, the inconvenience and 
suffering are also considerable, but the danger is by no means so urgent 
as in the former case. The same thing may be said of the larger bron- 
chial tubes; inflammation here is rarely attended with such violent symp- 
toms as those which characterise laryngitis, and it is much more amenable 
to treatment. But when inflammation attacks the minute bronchial tubes 
to any considerable extent, and particularly if it happens to be general — 
that is, if it affects the bronchial tubes in every part of the lungs — we have 
just grounds for alarm ; the disease is one of an intense character, and un- 
less quickly relieved, runs on to a fatal termination with great rapidity. 

You perceive, then, that if a patient catches cold, and gets an attack 
on the chest, it is of great importance to be able to ascertain what the 
situation and extent of the disease are, and whether the minute bronchial 
tubes are engaged or not. Now, how do you know this ? Simply thus: 
— You first make a cursory examination of the whole chest, by applying 
the stethoscope over the superior, middle, and inferior portion of each 
lung, both before and behind ; and, if you every where hear something, 
you conclude that the bronchitis is general, and not confined to any par- 
ticular part. You next proceed to examine with greater attention these 
wheezing sounds ; you apply the stethoscope, and if you find in each 
separate spot many sources of diseased sound — if you hear a wheezing from 
a great many points close together — you maybe sure that the morbid sound 
proceeds from inflammation of the minute tubes, for the larger ones can- 
not exist in the small spots over which you apply the stethoscope, in such 
numbers as to give rise to so remarkable a plurality of sounds. Of this 
you may be certain, that when you find a great many sounds are audible 
over a small space, the minute bronchial ramifications are engaged. 

It is the custom with those who lecture on auscultation, to enumerate 
many sounds as connected with alterations in the condition of the bron- 
chial tubes. We hear of the mucous, the sonorous, and the sibilant rhon- 
chus — their varieties and intermixtures. Now I know, by experience, 
that these names are very apt to confuse and perplex the young stethos- 



BRONCHITIS. 203 

copist. There is no necessity for studying with great attention the defi- 
nitions of these words, or the descriptions of the various sounds they are 
meant to represent : I am always anxious to avoid loading the memory 
of the student with names. With regard to the rales in bronchitis, all he 
need bear in mind is, that the nature of the sound produced by air passing 
through the bronchial tubes will be modified accordingly as these tubes 
are large or small, dry or moist, or as the moisture they contain is thin or 
not. The two things of greatest importance in examining a case of bron- 
chitis is to ascertain whether the minute bronchial ramifications are en- 
gaged, and, if the tubes contain any moisture, whether it is thin or viscid. 
I seldom, therefore, confuse the student by telling him whether the rale 
is sibilant or sonorous, when asked about the nature of the sounds heard 
in a case of bronchial inflammation. All I say in reply is this : that the 
sounds are produced by the large or small bronchial tubes, and that they 
are either moist or dry.* When the large bronchi alone are inflamed, 
the sounds issuing from the lung subjacent to the stethoscope are compa- 
ratively few in number, seldom exceeding two or three ; they are like- 
wise, when dry, of a grave tone, resembling the prolonged note of a vio- 
lincello, or the cooing of a dove ; or when moist, the bubbles are large, 
scattered, uneven. When the minute tubes are engaged, we hear, on the 
contrary, not a few, but many sounds, evidently proceeding from a small 
portion of lung; three, four, or even six or seven sounds may be perceived 
together, or circumscribed within very narrow limits. These sounds un- 
dergo rapid changes of tone during the same respiration, while every 
moment some of them appear to cease, to be replaced by new ones. The 
wheezing they produce is, when dry, sharp ; but observe, it is very unu- 
sual to find everyone of them dry: when dry sounds occur they are 
generally accompanied by others, equally minute, but evidently moist. 
The moment I find, on applying the stethoscope, that a great many sounds 
are heard over a small spot, and that these sounds are dry and sharp, or 
are accompanied by certain modifications denoting the passage of air 
through fluid, I call the disease inflammation of the minute bronchial 
tubes, with increased secretion obstructing the free entrance of air. An 
attention to these considerations is of great importance in ascertaining the 
nature of acute or chronic bronchitis ; for the danger is not only propor- 
tioned to the extent of the disease, but also the circumstances of the mi- 
nute tubes being engaged, and the quantity of fluid they contain. The 



* [When the inflammation is strictly confined to the largest bronchi, we 
sometimes hear no distinct rhonchus. The respiration is often feeble in 
certain portions of the lung and exaggerated in others, but there is no 
distinct rhonchus unless the tubes of medium size are either thickened or 
contain a small amount of liquid secretion ; when either of these condi- 
tions occurs, we hear the sonorous, sibilant, mucous, or sub-crepitant 
rhonchus. Frequently, as Dr. Graves says, two or three of these sounds 
are combined, and are heard at the same time, but as a general rule the 
liquid rhonchi are most distinct at the lower and posterior parts of the 
lung, while the dry rhonchi are scattered over the whole extent of it. The 
sub-crepitant rhonchus of course indicates that the smallest tubes are in- 
volved, and when this sound is dry, that is, when it is caused by bubbles of 
mucus, small in size, and which break in an equal manner, it often shows 
that the bronchitis is about passing into pneumonia. — W. W. G.] 



204 CLINICAL MEDICINE. 

sound shows that not only the minute tubes are diseased, but also that 
there is a considerable, quantity of viscid fluid in them, preventing the 
entrance of air into the air-cells, and tending to produce asphyxia. 

This man is, as you have seen, about the middle age in point of years, 
but he is old in constitution. In this country you will find most of the 
labouring poor exhibiting symptoms of premature old age — the combined 
result of poverty, intemperance, and hardship. Obliged to work in the 
open air in bad weather, they get catarrhal affections, which are renewed 
by repeated exposure, and prolonged for want of proper care. The natural 
effect of cold frequently renewed and generally neglected is, that a ten- 
dency is produced in the bronchial mucous membrane to become con- 
gested and inflamed with facility, until at length the derangement be- 
comes permanent, and the mucous membrane no longer returns to its 
normal and healthy condition during the intervals. 

The secretion of the mucous membrane of the bronchial tubes, in a 
perfectly healthy person, is almost entirely destitute of matter to be expec- 
torated. In the normal state, the secretion of the bronchial mucous mem- 
brane, though continually going on, scarcely ever exists in superfluous 
quantity, for a certain proportion of it is carried off by exhalation or ab- 
sorption ; a 'perfectly healthy 'per son , breathing a pure air, has no expectora- 
tion whatsoever. The moisture secreted by his bronchial mucous mem- 
brane contains nothing that the expired air cannot carry away in vapour, 
without leaving any residuum which, gradually accumulating, would at 
length require to be expectorated. In this respect the bronchial mucus 
in the healthy state differs from the mucus of other membranes of the same 
class: but disease destroys this beautiful provision, and gives rise to a 
secretion of morbid mucus which cannot be gotten rid of in the usual 
w T ay, and which therefore must be expectorated. Hence it is that persons, 
in whom a chronic state of congestion of the bronchial membrane has 
been generated by repeated colds, have a secretion of superfluous matter 
always going on, and are constantly expectorating. This may continue 
for several years without much inconvenience ; the principal annoyance 
the patient suffers is in getting up the phlegm in the morning. At this 
period there is always an accumulation of fluid in the lungs after the 
night, during which the cough is less frequent, and expectoration less 
copious. 

Here let me remark, that, although a person may cough violently 
during his sleep, he never expectorates. Expectoration is accomplished 
by the attention being directed to the chest, by an act of volition being 
put in force, so as to cause a constriction of the bronchial tubes, and 
generate a current of air of sufficient strength to expel the mucus. To 
effect this, the mere act of coughing is not sufficient, and consequently we 
do not expectorate during sleep ; for this purpose it is necessary for the 
patient to be awake. 

Frequently recurring catarrhal affections, besides generating a state of 
chronic derangement of the mucous lining of the lungs, have a necessary^ 
tendency to produce other bad effects. Dyspnoea is an ordinary attendant 
on chronic bronchitis; the vesicular tissue, enfeebled by disease, loses 
its natural elasticity ; and hence the act of respiration is performed weakly, 
and with considerable difficulty. In addition to this, the stress thrown on 
the air-cells and passages gives rise to emphysema and dilatation of the 
bronchial tubes. 



BRONCHITIS. 205 

When this man came into the hospital, he was labouring under an exa- 
cerbation of his chronic bronchitis, from a fresh attack of cold ; lie also 
suffered from dyspnoea, with a tendency to emphysema, and had been 
much debilitated by the frequent recurrence of his pulmonary symptoms. 
I do not intend to make any particular observations here on acute bron- 
chitis supervening on chronic ; it is a dangerous disease, requiring prompt 
and careful attention. I merely refer to this case to point out the remedies 
which were employed, and the principles which guided me in their 
selection. 

At the time of our patient's admission, the fever which accompanied 
the acute attack had subsided. His pulse was tolerably quiet, neither 
did he present any derangement of the heart's action, and, so far, had 
escaped one of the consequences of chronic disease of the lung — namely, 
dilatation and hypertrophy of the right ventricle. Observe, the most impor- 
tant features in this case, so far as treatment is concerned, were these : there 
was no general /inflammatory condition of the system present ; he had 
neither hot skin nor quick pulse ; his expectoration was copious ; the 
chest sounded well on percussion, and the only stethoscopic phenomena 
observed were extensive minute and moist bronchial rales. The case 
then stood thus: extensive bronchial inflammation with copious expecto- 
ration, unaccompanied by fever, and occurring in a debilitated constitution. 
All weakening measures were therefore contraindicated. It is true that the 
man had dyspnoea, and complained of tightness across his chest — circum- 
stances which might appear to demand the use of the lancet or leeches ; 
if these means had been employed, he would certainly have experienced 
some relief; but in the course of a few hours the symptoms of distress 
would have returned, the weakness superinduced by bleeding would give 
rise to increased secretion into the bronchial tubes, and the patient would 
be worse than before. Under these circumstances, we refrained from 
using the lancet or leeches ; but, deeming it advisable to get rid of the 
last traces of inflammatory action, we gave the following mixture : — 

R. Misturoe amygdalarura, 5xij. 
Nitratis potassae, £ij. 
Tartar, emetici, gr. j. 
Tinctur. opii camphorat. 5SS. 
Ft. mistura pectoralis, sumat cochleare j., amplum omni hora, vel urgente tusse. 

In explaining the rationale of this mixture, it is hardly necessary for me 
to state why the almond emulsion was used. In all cough bottles it is of 
importance that the basis should consist of some mild mucilaginous fluid ; 
And hence we generally employ for this purpose demulcent syrups, emul- 
sions made with olive oil, spermaceti, or almonds, or decoctions of muci- 
laginous seeds and roots. With the almond emulsion we combined tartar 
emetic and nitrate of potash — both antiphlogistic remedies, and calculated 
to act with peculiar effect in relieving congestion of the bronchial mucous 
membrane. You are aware that nitrate of potash in large doses is a 
powerful antiphlogistic, and you have seen it prescribed with excellent 
effects in cases of acute arthritis treated in this hospital. Nitrate of 
potash, when given to the amount of two or three drachms in the day, com- 
bined with two or three grains of tartar emetic, is, next to bleeding, the 
most efficient means we possess of reducing inflammatory action ; and 
were I to be asked what remedies I should employ in combating inflam- 



206 CLINICAL MEDICINE. 

mation — supposing there were no such things as the lancet, or leeches, 
or calomel — I should certainly say nitrate of potash and tartar emetic. 
When given in small doses, this combination proves also extremely ser- 
viceable in less severe cases, and it was on this account we gave it in the 
present instance. To this we joined the camphorated tincture of opium, 
convinced that its stimulant properties could not prove injurious when 
combined with antiphlogistics, although it would be improper to admi- 
nister it alone. Experience has taught that when camphorated tincture of 
opium is given, in cases of chronic cough with expectoration,- it will (if 
much inflammatory action be present) check the expectoration and bring 
on dyspnoea. But when combined with nitrate of potash and tartar 
emetic, its bad effects are corrected, while its sedative influence remains 
unimpaired. 

In addition to this, I ordered the nitro-muriatic acid liniment to be 
rubbed over his chest. This liniment we are much in the habit of pre- 
scribing where a rubefacient is required. It is made by diligently mix- 
ing one drachm of nitro-muriatic acid and one ounce of lard, by means 
of a wooden or ivory spatula. When this mixture is complete, two 
drachms of spirit of turpentine are added ; these ingredients" soon separate 
from, and mutually react upon each other, so that the liniment is spoiled ; 
we, therefore, never make it in large quantities. As his bowels were con- 
stipated, I gave him a pill composed of three grains of blue pill, quarter 
of a grain of colchicum, two grains of scammony, and half a grain of cap- 
sicum. Colchicum acts on the biliary secretion, particularly when com- 
bined with blue pill, and hence promotes the general action of the intes- 
tines. With these I combined a little capsicum, in consequence of the 
patient's complaining of being annoyed by constant flatulence. Itisacurious 
fact, that every chronic derangement of the bronchial mucous membrane is 
accompanied by flatulence. Whether this arises from the irritation of the 
bronchial membrane spreading by continuity of tissue, and rendering the 
tongue foul, the stomach weak, and the digestive function unnatural ; or 
whetherthe derangement of the bronchial mucousmembrane,andtheimper- 
fect performance of the function of respiration, cause the secretion of air 
from the lungs to be diminished, in consequence of which air is secreted from 
the intestinal mucous membrane by a vicarious action — I cannot exactly 
state, but I think the latter hypothesis not very improbable. It is well 
known that the mucous membrane of the stomach and bowels enjoys the 
power of secreting and absorbing air; it secretes carbonic acid, nitrogen, 
and also other gases which seem peculiar to it — such as sulphuretted hy- 
drogen. I am not aware that there is any distinct evidence that the last- 
named gas is ever secreted by the bronchial mucous membrane, but, as 
there are some cases in which the breath is remarkably fetid, I think it 
remains for future experiments to decide whether it may not be so under 
certain circumstances. It is, however, by no means improbable, that 
when an adequate cause produces considerable derangement in the respi- 
ratory function, and alters the nature of the aerial secretion from the lung, 
the mucous lining of the stomach and bowels may take on a vicarious 
action, and secrete gases analogous to those which in the normal state are 
secreted by the mucous membrane of the bronchial tubes. I think I have 
seen some well-marked examples of this translation of the function of 
secreting air from the pulmonary to the intestinal mucous system in cases 
of spasmodic asthma and hysteria. I have seen patients who, previously 



BRONCHITIS. 207 

to an attack of asthma, bad no symptoms of flatulence, and observed that, 
accordingly as the disease proceeded and the derangement of the respira- 
tory function increased, the bowels became distended with air. In hys- 
teria, also, where derangement of the respiratory function is plainly de- 
noted by the heaving of the chest, sighing, and dyspnoea, there is gene- 
rally enormous and sudden inflation of the belly, loud borbyrygrai are 
heard, and there is a constant disengagement of air upwards and down- 
wards. 

But to return to our patient. After we had removed all traces of active 
inflammation, and the case had been reduced to one of ordinary chronic 
bronchitis, we changed his cough-mixture for the following: — 

R. Misturae ammoniaci, 5vj. 
Carbonatis soda.', 3 SS - 
Tincturae opii camphorat. 5*8. 

hyoseyami, gj. 

Vini ipecacuanha?, 5pj. 
Fiat mistura pectoralis, sumat cochl. j. amp. pro. dope. 

The carbonate, of soda was given with the view of removing some acidity 
of stomach which he complained of; besides, it is a fact that alkalies pro- 
duce good effects in many cases of pulmonary irritation, as must have 
struck you from witnessing the success of the popular remedy for hooping- 
cough, recommended by Mr. Pearson. You will observe, gentlemen, how 
very different this cough-mixture is from the former, it is much more sti- 
mulating, and, at the same time, more powerfully anodyne, the opium 
being here less diluted, and being aided by henbane; the addition of 
ipecacuanha was intended to prevent a too speedy action on the part of 
the other ingredients, in diminishing the expectoration and constipating 
the bowels. 

I wish to call your attention to the plan of treatment, not with reference 
to this case alone, but with respect to chronic bronchitis in general. We 
first gave a combination of nitrate of potash and tartar emetic, with the view 
of removing any remaining traces of inflammatory action ; we next pre- 
scribed the misturaB ammoniaci, with camphorated tincture of opium and 
carbonate of soda, &c. ; and, finally, when the cough became entirely 
chronic, we gave the compound iron mixture, with tincture of hyoscyamus, 
in draughts, and an electuary, consisting of sulphur, cream of tartar, and 
senna. I need not repeat what you will find in every treatise on materia 
raedica, with respect to the use of the compound iron mixture; it is not 
to be given until all traces of fever and local inflammation are removed, 
and never until the secretion from the lungs is copious, and expectoration 
free. In such cases, the patient is generally weak, and the inordinate se- 
cretion adds to his debility. Here the compound iron mixture proves ex- 
tremely serviceable, but you should commence its use with caution. Some 
persons are in the habit of giving it in doses of half an ounce, two or three 
times a-day ; this I never do ; I begin with a drachm, twice or three times 
a-day, in an ounce of spearmint water, and add from half a drachm to a 
drachm of tincture of hyoscyamus. The dilution with mint-water, and the 
addition of tincture of hyoscyamus, render it more valuable, by causing it 
to be more easily borne by the system, and less likely to be rejected by 
the stomach. 

Let me now explain my reasons for ordering the following elecuary : — 



208 CLINICAL MEDICINE. 

R. Electuarii sennae, ^iij. 

Pulveris supertart. potassse, ^j. 
Sulphuris loti, ^ss. 
JSyrupi zingiberis, q. s. 
Ut fiat eleetuarium, sumat cochleare, j. parvum bis vel ter quoticlie. 

In the first place, when giving any stimulant medicine internally, it is es- 
sentially necessary to attend to the state of the bowels; in the next place, 
keeping the bowels freely opened, has a very remarkable effect in dimi- 
nishing inordinate secretion from the bronchial tubes. Where the patient's 
strength can bear it, I often diminish supersecretion from the lung by strong 
hydragogue purgatives, as you saw in the case of a patient in the chronic 
ward, who had orthopnea, and such an excessive secretion into the bron- 
chial tubes as to threaten suffocation. The patient being a strong man, 
and having no symptom of intestinal irritation, I prescribed a bolus, com- 
posed of a grain of elaterium, two of calomel, ten of jalap, and five of 
scammony, forming a powerful hydragogue purgative, which produced 
several fluid discharges. The man bore its operation well, and I repeated 
it in two days with the most decided benefit; indeed, he experienced from 
it more complete relief than he would have done from bleeding, blister- 
ing, or any other remedial means. In some cases of bronchitis with ex- 
cessive secretion, you will be able to produce very striking effects by the 
use of hydragogue purgatives; this, however, will require both judgment 
and discretion, and it should be borne in mind, that, in the majority of 
cases, there are many circumstances which contraindicate their employ- 
ment. 

With respect to the use of sulphur in this case, I was led to prescribe 
it, in this and many other similar cases, from observing that chronic cough, 
and long-continued congestion of the bronchial mucous membrane, were 
more effectually relieved by the use of sulphureous waters, such as the Lu- 
can and Horrowgate Spas, than by any other remedy that could be devised. 
I may here also observe that the Lucan waters produce very striking ef- 
fects in diseases of the skin, and that I have seen intractable cases of pso- 
riasis which lasted for years yield to the use of the Lucan waters. It 
would appear that sulphur, when taken into the system, is either elimina- 
ted by the kidneys in the form of sulphates, or exhaled from the skin and 
mucous tissues in the form of sulphuretted hydrogen, and in this way we 
arrive at some explanation of its action in diseases of the skin, and chronic 
irritation of the bronchial mucous membrane. In fact, paradoxical as it 
may appear, sulphur, although evidently stimulating, is nevertheless very 
efficacious in curing many diseases connected with, or depending on, in- 
flammation or congestion. Thus exhibited internally and properly com- 
bined, what remedy gives such prompt and certain relief in that painful 
affection, piles? How rapidly does the specific irritation of the skin, 
termed scabies, yield to its use? These, and similar facts, which might 
be brought forward in abundance, ought to countenance the use of this 
medicine in certain chronic inflammatory affections of the bronchial tubes. 
The celebrated Hoffman was in the habit of adding sulphur to his cough 
prescriptions in all cases of chronic bronchitis in the aged and debilitated; 
and I have no doubt that from five to ten grains of sulphur, taken three or 
four times in the day, is one of the best remedies that can be prescribed 
in cases of chronic cough, accompanied by constitutional debility and co- 
pious secretion into the bronchial tubes. Within the last four years, my 



BRONCHITIS. 209 

attention has been particularly directed to the use of sulphur in this and 
other affections, and I can state from experience that it is a most valuable 
remedy. As it has a tendency to produce elevation of the pulse, increased 
heat of skin, and sweating, it will be necessary to temper its stimulant 
properties by combining it with cream of tartar, which is a cooling aperi- 
ent, and has the additional advantage of determining gently to the kid- 
neys.* The addition of the electuary of senna gives additional value to 
the combination, and quickens its action on the intestines. 

Such, gentlemen, are the principles that guided me in prescribing for 
this man. The long continuance of the complaint, the serious and exten- 
sive derangement of the pulmonary raucous membrane, the age, debility, 
and impoverished circumstances of the patient, forbid me to hope for a 
perfect cure ; but he has been much relieved, and the same remedies 
applied to less desperate cases would have produced very striking effects. 
Still, if fortune were this moment to prove favourable to the poor fellow, 
if, when he leaves the hospital, instead of returning to hardship and ex- 
posure, he had the means of living in comfort, taking proper care of him- 
self, travelling for health and amusement, and using a course of chalybeate 
Spa waters, I have little doubt that with these aids the reparative powers 
of nature would succeed in obliterating every trace of pulmonary derange- 
ment. 

There is in the small chronic ward another case of chronic bronchitis, 
in a man named Murray. The disease is of very long standing, and has 
undergone many exacerbations. It is a case in which I am afraid a per- 
manent cure is out of the question, and so far it is unsatisfactory ; but it 
is still necessary to be acquainted with such cases, for it is a matter of 
some importance to be able to inform a patient whether his disease is 
curable or not, and how far it admits of being relieved by treatment. 

In Murray's case we found, on examining the chest, that the minute 
bronchial tubes were extensively engaged, and they were obstructed by a 
copious secretion of mucus producing considerable dyspnoea. We found, 
however, that this condition had lasted for many months, and that the 
disease was essentially chronic. He had no fever ; his skin was cool ; 
his tongue moist ; appetite and digestion good ; and his pulse, which had 
been only 60 on his admission, sank to 46 after he had been in bed for 
some days. Such extreme slowness of pulse as this is a very remarkable 
circumstance, particularly in cases of pulmonary disease : it is seldom met 
with except in cases of cerebral affections. Here was a man breathing 
twenty-six times in a minute, and with a pulse at 46 ; whereas, if the 
pulse was proportioned to the respiration, it would have been much 
quicker. The relation of the number of respirations to the beats of the 
artery at the wrist should be as one to four ; thus, when we breathe fifteen 
times in a minute, the pulse should be at 60. But here we find a man 
breathing twenty-six times in a minute, and yet his pulse is only 46. We 
had another instance like this, in a patient in the chronic ward, whose 
pulse was 60, while his respirations were thirty-six in a minute. It seldom 
happens, when pulmonary disease is in the acute form, and respiration 
considerably accelerated, that there is not a corresponding increase in the 
frequency of the pulse ; but, in chronic cases of this description, the sys- 
tem becomes gradually accustomed to the derangement ; the continued 
acceleration of breathing ceases to affect the action of the heart; the lung, 

* Baglivi has well said, " In morbis pectoris ad vias urinse ducendum est." 

15 



210 CLINICAL MEDICINE. 

which is obstructed by disease in the performance of its functions, con- 
trives, by working more frequently, to aerate the requisite quantity of 
blood, and, the heart adapting itself to the change of circumstances, the 
pulse returns gradually to the natural standard. I have seen many cases 
of phthisis, in which there was accelerated breathing, with slow pulse, 
but these were always cases of a chronic kind. I have never observed 
the same phenomena coexisting when the disease was acute; it is a state 
of things which is compatible only with chronicity of disease, in which 
the system becomes gradually accustomed to the change, and -a kind of 
artificial equilibrium is finally established. 

In this case we find that a man of tolerably good constitution, after ex- 
posure to cold, gets an attack of bronchitis, which becomes chronic, and 
extends almost over the whole lung. He has a cough always existing — 
sometimes better, sometimes worse, occasionally aggravated. This cough 
is accompanied by a copious secretion of mucus ; and this state of things 
continues for more than twelve months. Now, when bronchitis has lasted 
so long on persons of his class in life, it is very difficult to be cured ; his 
poverty, his want of proper clothing, his liability to the ordinary exciting 
causes of bronchitis from the nature of his employment, and the habitual 
disregard of self so constantly observed in persons of this description, are 
all circumstances which forbid us to entertain any hopes of giving perma- 
nent relief. 

There are two points to be attended to in the treatment of this and 
every other case of chronic bronchitis ; first, whether there be any recent 
attack, and consequently any fever and exacerbation of the local symp- 
toms present; and, in the next place, whether the secretion from the 
bronchial mucous membrane be copious or scanty. Now, at the period 
of this man's admission, there was some slight excitement of the pulse, 
but there was no fever or increase of bronchial inflammation present, and 
the heart's action was apparently not influenced by the state of the lung. 
In addition to this, there was no urgent dyspnoea, and the secretion from 
the lungs was extremely abundant. We therefore commenced by admi- 
nistering an emetic, which was repeated for two or three days, and then 
prescribed the following mixture : mist, ferri compositee, ^ij . ; tinct. scillas, 
tinct. hyosciami, aa 9j. ; to be taken three times a-day, in an ounce of 
almond emulsion. In chronic bronchitis, where no fever, no remarkable 
dyspnoea or acceleration of the pulse is present, and where the bronchial 
secretion is very copious, you will be able to produce very good effects by 
giving an emetic every night for two or three nights, before you begin 
with remedies calculated to arrest the supersecretion from the lung. They 
are productive of a double advantage in such cases: a large quantity of 
mucus is discharged from the stomach and lungs, expectoration is ren- 
dered more easy, the tongue cleans, and the appetite is improved. It 
was on this account we gave them in the present case, and as you have 
perceived, with much benefit. In no disease are we more apt to have a 
foul, loaded, and furred tongue, than in bronchitis. This state of the 
tongue, being usually accompanied by loss of appetite and indigestion, is 
frequently attributed to a bad stomach. Now, the truth is, that in such 
cases the state of the tongue and the state of the stomach are both pro- 
duced by one and the sarm j cause — viz., the unnatural state of the bron- 
chial mucous membrane. In the latter tissue the train of morbid actions 
commenced, and from it was derived that source of irritation which, indu- 



BRONCHITIS. 2J1 

cing disease in the bronchial mucous membrane, caused a state of parts 
rapidly propagated along that membrane to the mouth and tongue on the 
one hand, and to the stomach on the other. We afterwards had recourse 
to a tonic and astringent chalybeate — the mist, ferri comp. — with the view 
of improving the general system, and checking the superabundant secre- 
tion from the bronchial tubes. The action of a chalybeate is not merely 
limited to strengthening the tone of the stomach and general system ; it 
is also well calculated to arrest the superabundant secretion from mucous 
surfaces in many chronic fluxes, and hence its utility in gleet, diarrhoea, 
and chronic bronchitis. We gave the compound iron mixture in prefer- 
ence to a simple chalybeate, because the other ingredients — namely, 
myrrh and subcarbonate of potash— have a tendency to produce the same 
effect. I do not, however, prescribe this medicine in such large doses as 
I have frequently seen ordered, and I never give it alone. I order a 
drachm or two to be taken three times a-day, and f dilute this quantity 
by adding to it half an ounce or an ounce of almond emulsion or mint- 
water. In this form it is a much safer remedy in the treatment of fluxes 
depending on chronic inflammation, and its exhibition is much less likely 
to be followed by sinister accidents. I have, in the present in>tance, 
combined with it a small quantity of squill ; the reason of making this 
addition is so obvious, that it is unnecessary for me to do more than notice 
the fact. I have also added some tincture of hyoscyamus, which is an 
extremely valuable sedative in the treatment of many forms of pulmonary 
disease. 

However well planned this treatment seemed to be, it did not succeed. 
After taking the mixture for a day or two, the man began to complain of 
tightness across his chest, and we were obliged to give it up. I have 
already stated, that in cases of this description, where the patient is using 
remedies to arrest secretion, you should be cautious in administering them 
at first, and attend carefully to their effects. If, after a patient has been 
using a chalybeate, or any remedy administered for similar purposes, you 
find that constriction of the chest and dyspnoea is increased, no matter 
whether the secretion is diminished or not, you may be sure that you are 
doing more harm than good. When the remedy acts favourably, you 
may know it by the following signs: — respiration becomes less frequent, 
and is performed with less distress, the expectoration becomes more free, 
the sputa begins to assume the globular form, its quantity is diminished, 
and it is less tenacious and viscid in its consistence. When you give a 
stimulant, therefore, in chronic bronchitis, you must watch its effects with 
care, and if it produces any increase in the difficulty of respiration, or 
any pain or tightness of chest, you must omit it altogether, and pass to an 
expectorant of a less irritating character. In this case, we stopped the 
use of the mistura ferri composita, and immediately ordered the patient to 
take a grain of tartar emetic in a pint of whey. This simple remedy suc- 
ceeded in a very remarkable manner, producing on the first day a very 
considerable alleviation of symptoms. 

There is another patient about to leave the hospital to-day, on whose 
case I wish to make some observations. This young man, whom you 
have seen lying in the chronic ward, in the bed next but one to Byrne's, 
caught cold about seven or eight months ago, followed by cough, wheez- 
ing, and dyspnoea, which, after a month or six weeks, subsided. About 
two months before he came into the hospital, he renewed his cold, and 



212 CLINICAL MEDICINE. 

with it the cough and dyspnoea returned. On his admission, he com- 
plained of difficulty of breathing, which attacked him every night ; he 
went to bed well, and slept tranquilly for two or three hours, and then 
was awakened by pain and sense of tightness in the chest, with great dys- 
pnoea. When the paroxysms came on, it compelled him to get up and 
walk about the room, gasping for breath ; and, after continuing for two or 
three hours with great dyspnoea, wheezing, anxiety, and cough, went off 
with free expectoration and sweating. As soon as the sweating and 
expectoration appeared, he lay down without any inconvenience, and 
slept quietly until morning. The only additional symptom he complained 
of was palpitation of the heart, which sometimes affected him when em- 
ployed at hard labour. On examining the lungs there was nothing found 
except a few bronchitic rales. The heart was normal in its action, and 
no morbid sound could be detected by the stethoscope. In addition to 
this, you will recollect that the man was in the prime of life, had a full 
and well-informed chest, a quiet pulse, regular bowels, and a good 
appetite. 

Here you perceive a man from repeated colds gets chronic irritation of 
the bronchial tubes, and this induces asthmatic paroxysms, which come 
on, as is usual in such cases, at a certain hour oT the night. It was plain, 
therefore, that he was labouring under a well-marked form of asthma, a 
disease which, in its pure and simple state, is seldom met with in hos- 
pitals, being generally observed in connection with the disease of the 
heart, or long-continued bronchitis in old persons. Chronic bronchitis is 
one of the most common causes of asthma ; indeed, you will scarcely ever 
meet a patient who has been subject to chronic irritation of the bronchial 
tubes, who does not also labour under more or less asthmatic dyspnoea. 
The disease is generally met with in persons advanced in life, and who 
have suffered from repeated attacks of bronchitis ; it is not usual to find 
it in so young a man as this patient, and presenting, as he does, such 
very slight symptoms of derangement of the bronchial mucous membrane. 

This case exhibits a remarkable proof of what may be done by simple 
means in relieving an urgent disease. The man was, with the exception 
of asthma, in good health ; his bowels were regular, his appetite good, 
his pulse tranquil, and the signs of pulmonary irritation trifling. There 
was no necessity, then, for administering remedies to improve the tone 
of the digestive organs, nor were we authorised to use the lancet or apply 
leeches. I therefore confined my attention to two points: the application 
of irritants to the neck and chest externally, and the internal use of re- 
medies calculated to relieve bronchial irritation. I ordered him to rub 
the nape and sides of the neck, and the fore parts of the chest, with a 
liniment composed of strong acetic acid, Jss., spirit of turpentine, 3 i ij - , 
rose-water, 3iss., essential oil of lemons a few drops, and yolk of egg in 
sufficient quantity to suspend the turpentine. This liniment is an imita- 
tion of the celebrated liniment of St. John Long. I gave a bottle of the 
real liniment to Dr. Apjohn,to analyze, and he thinks it consists of acetic 
acid, spirit of turpentine, and two animal matters, one containing azote, 
the other not ; the latter probably some species of fat, probably goose- 
grease. Now this fat did not exist in St. John Long's liniment in the 
form of soap, it was evidently some kind of fatty matter blended with 
water, probably by means of trituration with yolk of egg. The active 
ingredients are spirit of turpentine and strong acetic acid. This liniment 



ASTHMA. 213 

should be applied by means of a sponge. It acts as a rubefacient, and 
generally induces an eruption of small pimples after a few applications. 
The spirit of turpentine must be well mixed with the water (which ought 
to be added to it gradually) by means of yolk of egg, before the acetic 
acid is added. 

With this liniment our patient was desired to rub the fore part of the 
chest, and the nape and sides of the neck. It was applied to the chest 
with the view of relieving the bronchial irritation, and we ordered 
it to be rubbed over the nape of the neck, along the course of the cer- 
vical portion of the spinal marrow, and over the sides of the neck along 
the course of the pneumogastric nerve, because all the organs to which 
the latter nerve is distributed, are evidently affected in cases of spas- 
modic asthma. Thus a paroxysm of asthma is not only attended with 
increased action of the heart, dyspnoea, and hurried breathing, but also 
with marked derangement of the stomach, particularly towards the termi- 
nation of the fit, when the patient generally has a feeling of uneasiness in 
the stomach, with flatulence and a sense of fulness, induced probably by 
the derangement of circulation in the lung. You are aware of the close 
sympathy which exists between the stomach and lungs, and you must 
have been struck with the fact, that stimulant and irritating remedies ap- 
plied to the epigastrium often relieve affections of the lung more com- 
pletely than when applied to the chest. Thus in using the tartar-emetic 
ointment for the relief of hooping-cough, it has been found to act most 
beneficially when applied over the region of the stomach ; and the same 
thing may be said of Roche's embrocation, which does more good when 
rubbed over the spine or epigastrium, than when applied to the parietes 
of the thorax. On these principles, I ordered the counter-irritation to be 
applied over the course of the cervico-spinal and pneumogastric nerves, 
over the chest, and subsequently over the stomach. 

This liniment in a very short time produces redness and heat of the 
parts to which it is applied, and it is more than probable that its effects 
are not limited to temporary rubefacience, but that it also acts on the ner- 
vous system. We have innumerable proofs that turpentine exercises a 
special influence over the nervous system, and we know that it is rapidly 
absorbed even without the aid of friction. I fear, however, that we shall 
never be able to confer on our liniment all the wonderful properties attri- 
buted to that of St. John Long. You know it has been asserted that St. 
John Long's liniment never reddened the skin, except over the exact spot 
where disease was situated. I was assured by a young lady who used 
this liniment, that she rubbed it all over the chest, and that it produced 
no discoloration of skin, except in two spots where she felt pain. She at 
first mentioned but one spot which was painful, but St. John Long, hav- 
ing applied the liniment himself, told her she had deceived him, and that 
there was pain in another spot. It had other effects equally miraculous. 
An eminent Dublin lawyer declared that it drew nearly a pint of water 
from his head, and Lord Ingestre testified that it extracted quicksilver 
from his brain ! These, and other wonderful stories, told by several 
persons of distinction with a full belief in their authenticity, furnish a 
useful lesson to mankind, showing that gross credulity is not confined 
exclusively to the poor and the ignorant, but may be found among the 
highest classes of society. It is a singular fact also, and illustrative of 
the tendency which exists in human nature to deceive and be deceived, 



214 CLINICAL MEDICINE. 

that notwithstanding the repeated failure, and even fatal effects, of St. 
John Long's applications, many persons still regard his opinion as oracu- 
lar, and look upon his remedies as inestimable discoveries. When I men- 
tioned to the gentleman who brought me the bottle of liniment, that St. 
John Long himself died of phthisis, and brought this forward as a strong 
argument against the infallible efficacy of his remedies, he said that this 
very circumstance was one of the most remarkable proofs of his sagacity, 
for St. John Long had always maintained that the liniment was not suited 
to his own case, and that there was something in his constitution which 
neutralised its good effects ; and so it happened, for when he applied the 
liniment to his skin it did not produce the red spots which usually re- 
sulted from its application in other persons. In fact, such was the cre- 
dulity of St. John Long's patients, that his death passed among them as 
the strongest proof of the infallibility of his medicines. Indeed he is con- 
sidered by many of our nobility as a sort of medical martyr, who, having 
sacrificed life in the accomplishment of his mission, rising from earth, let 
his mantle fall on the highest bidder! 

But to return to our patient. In this case the liniment did a great deal 
of good, but it was not the only means we employed. We observed that 
the asthmatic paroxysm came on every night, continued for two or three 
hours, and then went off with free expectoration and sweating. In order 
to prevent this, we gave him a draught, which he was to take when 
awakened by the pain and sense of tightness in his chest. He took this, 
and it had the effect of arresting the paroxysms, so that he no longer 
found it necessary to leave his bed. That this remedy had succeeded in 
averting the disease, was plain from the following circumstance : — one 
day the clinical clerk had omitted to repeat his draught, and he conse- 
quently got no medicine ; on that night the asthmatic paroxysm returned 
and went through its usual course as before. This draught was very 
simple, being composed of half a drachm of tincture of hyoscyamus, half 
a drachm of vinegar of squills, and the same quantity of ipecacuanha 
wine in an ounce of camphor-mixture. It is scarcely necessary for me to 
explain the intention of the ingredients. The tincture of hyoscyamus 
possesses narcotic and antispasmodic properties, and ipecacuanha and squill 
are known to have great efficacy in disease of the bronchial mucous mem- 
brane, being both promoters of expectoration, and the latter also acting on 
the urinary organs. Without, however, attempting to explain the precise 
mode in which each of these ingredients acted, it will be sufficient to 
state that the combination had a beneficial effect, and checked the asthmatic 
paroxysms. We persevered in using it, as well as the liniment, until all 
tendency to asthma had disappeared, and the normal state of the function 
of respiration became perfectly re-established. 

Permit me, gentlemen, to make a few observations here on what is 
popularly termed cough. What is cough ? A sudden and violent expul- 
sion of air from the lungs, produced by forcible contraction of the dia- 
phragm, aided by the abdominal and other expiratory muscles. What is 
the cause of cough ? Pulmonary irritation. What is the nature of this 
pulmonary irritation ? 

Here, gentlemen, is a question which every practitioner should put to 
himself when called on to treat a case of cough, and what affection is 
there which so frequently demands our assistance, and tasks our inge- 
nuity? How abundant, how varied, are the examples of cough we 



COUGH. 215 

meet with in our daily practice! How obscure do we not find its nature 
on many occasions, and how difficult and perplexing its treatment ! 
Where the source of irritation is manifest, where the nature of the disease 
is simple and easily detected, where, after a proper examination, we can 
point to some part of the respiratory system, and say here is the seat of 
the disease ; in such cases, indeed, our course is sufficiently clear ; we 
may proceed with confidence, and practise with success. But how often 
are we, after weeks and even months of close and painful attention, baffled 
in our best-directed efforts, and forced to admit the humbling conviction 
that all our remedies are inefficient and useless, and that our character, 
as well as that of the profession, is likely to suffer in public estimation! 
How often, too, do we discover with surprise, that the cough which we 
have been treating for weeks as a pure pulmonary affection, depends not 
on any primary derangement of the respiratory system itself, but upon the 
irritation of some distant organ, or upon peculiar conditions of the whole 
economy ! 

Before I proceed to inquire into the nature of the various sources of 
pulmonary irritation producing cough, I wish to remark that the exciting 
cause, or, in other words, that which immediately precedes and seems to 
give rise to a tendency to cough, is a sensation of tickling in the mucous 
membrane of the trachea, close to its bifurcation, and opposite the hollow 
at the fore part of the neck. It is also a curious fact that this sensation of 
tickling or itching is peculiar to this situation, being never felt in any 
other part of the pulmonary mucous system. Whether the disease be 
seated above, as in case of laryngeal affections, or whether it be below, 
as in case of disease of the lining membrane, or parenchyma of the lung, 
it is here alone that the tickling sensation is felt. Another circumstance 
equally remarkable, and equally difficult of explanation, is the effect of 
position in cough. Persons labouring under slight bronchitis, or rather 
slight inflammation of the trachea, who scarcely cough half a dozen times 
in the course of the day, will, the moment they lie down at night, be 
seized with a violent and harassing cough, which may last for several 
minutes, and sometimes for hours, with little intermission. We can easily 
understand why empyema or pneumonia of one side of the chest may 
produce cough in certain positions and not in others, for here we have an 
obvious physical cause ; the accumulated fluid in the pleural cavity in 
the one case, and the diseased lung, whose specific gravity has been much 
increased by solidification, in the other, exercise an inconvenient degree 
of pressure on the sound lung, and hence give rise to irritation and cough, 
particularly in those positions which favour the operation of such physical 
causes of irritation. Here, however, the cause of irritation is very 
obscure. It may (but this I merely offer as an hypothesis) depend on the 
fluid secreted by the mucous membrane trickling over that part of the 
trachea where the tickling sensation is felt, the flow of mucus to this part 
being favoured by the recumbent position. That it does not depend on 
any supposed temporary congestion and irritaiion of the lung, from the 
impression made on the skin by cold bed-clothes, I am quite convinced, 
for I have repeatedly observed it in persons warmly dressed, from merely 
lying down on a sofa close to the fire. You will, therefore, bear in mind, 
gentlemen, that although usually, when coughing is induced by any sud- 
den change of position, we may infer that it is connected with some serious 
lesion of the lungs or pleura, yet we must not attach_too much importance 



216 CLINICAL MEDICINE. 

to this symptom, for cases are occasionally met with, in which mere tracheal 
or bronchial inflammation is attended with the same symptom to a very 
remarkable degree. 

I may observe en passant, that the sensation of tickling or itching ap- 
pears to be almost exclusively confined to the skin. Here it appears to be 
dependent on slight causes, apparently incapable of producing that modi- 
fication of nervous sensation termed pain. In other cases it seems to be 
connected with the rise and decline of the phenomena which indicate in- 
flammatory action, arising, in the first case (where it is generally less ob- 
servable) from that nervous modification which precedes inflammation; 
and, in the second, being connected with some change in the nerves of 
the part which announces its return to a healthy condition. It does not 
appear to affect the mucous tissues, except in a very slight degree, and 
under peculiar circumstances. It is not observed in the pulmonary mu- 
cous tissue, except at that part of the trachea which I have already men- 
tioned, and it does not occur in any part of the intestinal mucous mem- 
brane. The only parts connected with the intestinal tube, in which it is 
felt, are the nose and the anus, and here it is within the reach of scratch- 
ing, the ordinary mode of relief. This is a fortunate circumstance, gentle- 
men, for if any part of your bowels were to itch as your skin sometimes 
does, the annoyance would be quite intolerable. If the presence of lum- 
brici in the small intestines, instead of producing a troublesome itching of 
the nose — if it produced, I say, a degree of itching equally intense in the 
mucous membrane of the bowels and stomach, what patient could endure 
greater torments than a person so afflicted? If ascarides gave rise to as 
intense a degree of itching within the colon as they occasion at the verge 
of the anus, how dreadful would be the suffering thus induced! 

Passing over the obvious and well-known sources of pulmonary irrita- 
tion, producing cough, such as bronchitis, pneumonia, &c, the first cause 
to which I shall direct your attention is one of not unfrequent occurrence 
and where a mistake in diagnosis may lead to a practice useless to the pa- 
tient and discreditable to the practitioner. The best mode of illustrating 
this is by giving a brief detail of a case which I attended with Dr. She- 
kelton. A young lady, residing in the neighbourhood of Dorset Street, 
was attacked with symptoms of violent and alarming bronchitis. The fits 
of coughing went on for hours with extraordinary intensity; it was dry, 
extremely loud, hollow, and repeated every five or six seconds, night and 
day, when she was asleep as well as when she was awake. Its violence 
was such that it threatened, to use a vulgar but expressive phrase, to tear 
her chest in pieces, and all her friends wondered how her frame could 
withstand so constant and so terrible an agitation; and yet she fell not 
away proportionably in flesh, had no fever, and her chest exhibited nothing 
beyond the rales usually attendant on dry bronchitis. She was bled, 
leeched, blistered, and got the tartar-emetic mixture, but without experi- 
encing the least relief. We next tried antispasmodics, varying and com- 
bining them in every w T ay our ingenuity could suggest, still no change. 
We next had recourse to every species of narcotics, exhibiting in turn the 
different preparations of conium, hyoscyamus, opium, and prussic acid, 
but without the slightest benefit. Foiled in all our attempts we gave up 
the case in despair, and discontinued our visits. Meeting Dr. Shekelton 
some time afterwards, I inquired anxiously after our patient, and was sur- 
prised to hear that she was quite recovered ami in the enjoyment of excel- 



COUGH. 217 

lent health. She had been cured all at once by an old woman. This vete- 
ran practitioner, a servant in the family, suggested the exhibition of a large 
dose of spirit of turpentine, with castor-oil, for the purpose of relieving a 
sudden attack of colic: two or three hours afterwards the young lady 
passed a large mass of tape worm, and from that moment every symptom 
of pulmonary irritation disappeared. 

'The next kind of cough, in which the cause of pulmonary irritation is 
often misunderstood, is that which occurs in hysteric females. This cough 
constitutes one of the most alarming diseases in appearance you can pos- 
sibly witness; in some, it is loud, ringing, incessant, and so intensely vio- 
lent, that one wonders how the air-cells or blood-vessels escape being 
ruptured. In others, it is quite as incessant, occurring every two or three 
seconds, night and day, but is not very loud, and, indeed, in some it 
scarcely amounts to more than a constant teazing hem ; in general, the 
pulse is quick, but it is the quick pulse of hysteria, not of inflammation or 
fever. The patient suffers no aggravation of the cough from inspiring 
deeply, and her countenance exhibits no proof of malaefation of the blood, 
on the contrary it is blanched and pallid. She complains of variable or 
deficient appetite, headache, cold feet, and irregular or absent catamenia, 
and notwithstanding the cough continues for weeks or even months, 
she does not emaciate like a person in incipient phthisis, although so 
much disturbed by the cough, and subsisting on so small a quantity of 
food. 

Here the history of the case, a knowledge of the patient's habit, and 
the use of the stethoscope, are of great value. You will find that the 
patient is subject to hysteria, that she is generally pale and of a nervous 
habit, that the attack came on suddenly, and was superinduced by mental 
emotion, or some cause acting on the nervous system, or else arose gra- 
dually as one of the sequelae of catamenial disturbance, that the heat of 
skin and state of pulse are by no means proportioned to the violence of 
the symptoms, and the stethoscope will tell you that the signs of organic 
derangement of the lung are absent. You will thus be enabled to arrive 
at an accurate notion of the nature of the disease, and you will save the 
patient from the useless and often dangerous employment of antiphlogistic 
means. Eleeding and leeching are, generally speaking, injurious ; such 
cases are best treated by stimulants, antispasmodics, and stimulant purga- 
tives, together with change of air, travelling, and the use of chalybeate 
Spa waters.* 

The third species of obscure cough, to which I shall direct your atten- 
tion is one of deep importance for many reasons. It is that species of 
cough which depends upon pulmonary irritation connected with a vene- 
real taint in the system. That syphilis may attack the pulmonary as well 
as the cutaneous, osseous, mucous, and other tissues, is not a discovery 

* [The class of cases to which Dr. Graves here alludes, though rare, is 
sometimes met with. A very puzzling one of the kind occurred some 
years ago in a young lady, whom I saw, in consultation with Dr. Jackson, 
of this city. It was a case which resembled in some respects incipient 
phthisis ; there was, however, little emaciation, and none of the usual 
physical signs of tuberculous disease could be found. We directed for 
her a good nutritious diet, tonics, and the use of counter-irritants to the 
spine. Under this treatment she finally recovered. — W. W. G.] 



218 CLINICAL MEDICINE. 

of modern times ; it is a form of the disease long known, and you will 
find it mentioned by many of the old writers.* Since syphilis has been 
classed by Willan and others among diseases of the skin, this notion seems 
to have been either abandoned or forgotten, but, as it strikes me, with 
very little justice. I entertain a firm conviction that syphilis may afFect 
the pulmonary as well as it does the cutaneous, or mucous, or osseous 
tissues, and that a patient, labouring under a venereal taint, may have 
irritation from this cause set up in the lung as well as in any of those 
organs in which it is usually manifested. The first person who mentioned 
this circumstance to me was the late Mr. Hewson, and since that time I 
have had repeated opportunities of confirming the truth of his opinion. 
Richter, Alibert, and Paget, have well observed, that Willan and Bate- 
man's classification of diseases of the skin is liable to the paramount ob- 
jection, that it has no reference to the constitutional origin of cutaneous 
affections. I have the very same fault to find with modern treatises on 
diseases of the lungs. Pathologists have indeed inquired most accurately 
into the numerous morbid changes to which the pulmonary tissue is sub- 
ject, but they have omitted a no less important part of their % task, which 
is to investigate the states of constitution which originated these changes. 
The agency, indeed, of scrofula has been investigated with care, but how 
little attention has been paid to rheumatism, gout, syphilis, and scurvy, 
the fruitful sources of numerous diseases of the chest. 

By far the most interesting point connected with this affection is its 
diagnosis ; on this every thing depends. The great importance attached 
to the diagnosis arises from the circumstance of this disease presenting 
symptoms analogous to, and consequently being frequently confounded 
with, phthisis. A patient comes to consult you for cough ; you find him 
pale, emaciated, and feeble ; he sleeps badly, and is feverish at night, 
and has a tendency to sweat. Here there may be a double source of 
error. If the disease be mistaken for tubercle, and mercury not given, 
bad consequences will result ; on the other hand, if tubercles be present, 
the effect of administering mercury will be to precipitate the disease to a 
fatal issue. 

What is the nature of this disease, and how are you to recognise it ? 
Mainly, I answer, by the history of the disease. If the patient's suffer- 
ings have commenced at the period of time, after primary sores on the 
genitals, when secondary symptoms usually make their appearance ; if 
some of his complaints are clearly traceable to this source ; if, along with 
debility, night-sweats, emaciation, nervous irritability, and broken rest at 
night, we find cough ; and if this group of symptoms have associated 
themselves with others, evidently syphilitic — such as periostitis, sore 
throat, and eruption on the skin — then w T e may, with confidence, refer 
all to the same origin, and may look upon the patient as labouring under 
a syphilitic cachexy, affecting the lungs as well as other parts. In form- 
ing this diagnosis much caution and care are necessary, and we must not 

* The Germans were also aware of this circumstance. " Auch das Quecksilber hat die Emp- 
fehlunu'en einiger Aerzte, und noch neulich Hecker's erhalten. Demungeachtet passt es als 
ein stark Oxydirendes Mittel in der Lungens schw'mdsucht nicht, am wenigsten in der 
Phthisis pulmonalis ulcerosa. Hochstens kann es seinen Platz in der Phthisis tuberculosa 
finden, wo diese namlich scrophulosen oder syphilitischen Ursprung ist, jedoch auch hier nur 
in Anfange der krankheit, und stets nur in Verhindung mil dem opium und dem Hyosciamus." 
— Ueber die Erkenntniss und Cur der Chronischen Krankheiten des Menschlichen Organ- 
ismus von Dr. Wiluklm Andbeas Haase. 



COUGH. 219 

draw our conclusion until we have repeatedly examined the chest by 
means of auscultation and percussion ; if these fail to detect any tangible 
signs of tubercles, or if we discover only a trifling amount of disease in 
the lungs, whilst the constitutional symptoms are those that usually attend 
the advanced stages of phthisis, we may then proceed to act upon our 
decision and may advise a sufficient but cautious use of mercury. Under 
such circumstances, it is most pleasing to observe the speedy improve- 
ment in the patient's looks and symptoms ; the fever, night-sweats, and 
watchfulness diminish ; he begins to get flesh and strength, and, with the 
symptoms of lues, the cough and pectoral affection disappear. I am not 
prepared to say which of the pulmonary tissues is most usually attacked 
by the venereal poison, but I believe that it chiefly tends to the bron- 
chial mucous membrane, although, like other animal poisons — e. g. 9 
those of measles and scarlatina — it may also occasionally produce pneu- 
monia.* 

The fourth species of obscure pulmonary irritation, producing cough, is 
that which is connected with a gouty diathesis. Gout may attack almost 
every tissue in the body. We may have it in the joints, as you are all 
well aware ; we may have it in the muscles and muscular aponeuroses, 
forming what has been termed the rheumatic gout ; it occurs frequently in 
the fibrous tissues, and I have several times observed it in the cellular 
substance of various parts of the body, forming either diffuse edema or 
tumours, which are exceedingly tender to the touch, and are removed by 
treatment calculated to relieve the constitutional affection. It may attack 
the heart, giving rise to true pericarditis, or else to a functional disease 
with palpitations — a sensation of fluttering and sinking about that organ, 
and very remarkable intermission of the pulse ; or it may affect the sto- 
mach, occasioning dangerous spasm or various dyspeptic symptoms ; or it 
may seize on the intestines, producing irritation, colic, and gouty diar- 
rhoea. I remember a patient, of a confirmed gouty habit, expressing a 
great deal of surprise at getting an attack of gout in the testicle, for he 
could not conceive how a disease which generally affects the joints could 
occur in an organ so different in its nature. I replied, that the matter 
could easily be explained ; because fibrous tissue, which gout most fre- 
quently attacks, enters into the composition of the testicle as well as that 
of the joints. Indeed, the testicle, with reference to the texture of its 
envelopes and the extent of motion it enjoys, may be said to be provided 
with a sac-like joint. In like manner, gout very frequently attacks the 

* In page 93 of Ur. S?tq» ks's celebrated work on the" Diseases of the Chest" we fuul the 
following passage in confirmation of the views advanced above : '• My friend, Dr. Byrne, 
whose situation, as a medical officer of the Lock Hospital, gives him the greatest opportunities 
of observation, informs us that he has, in many instances, seen patients who had been formerly 
diseased, and who had come into hospital either for new sores or for gonorrhoea, attacked with 
intense bronchitis and fever. This attack would come on suddenly, and the distress was so 
great, that bleeding had to be performed, the effect of which was. that soon after, a copious 
eruptfion often combining the lichenons and squamous forms, made its appearance with com- 
plete relief of the chest. In some of these patients, on the day before the eruption, the stetho- 
scopic signs had been those of the most intense mucous irritation ; and yet, when the skin dis- 
ease appeared the respiration became either perfectly pure or only mixed with an occasional 
rhonchus in the large tubes. The same gentleman has observed the reverse of this, as when a 
syphilitic eruption has been repressed, the bronchial membrane has become much engaged, and 
the patient affected with general febrile symptoms. These phenomena subsided after bleeding 
and mild diaphoretics, which had the effect of restoring the cutaneous eruption. Here," ob- 
serves Dr. Stokes, " we have an additional evidence in favour of the analogy between this 
syphilitic bronchitis and that of the exanthemata." 



220 CLINICAL MEDICINE. 

mucous membrane of the trachea or bronchial tubes, causing a dry, 
annoying, and often a very obstinate cough. Where this cough comes on 
along with the fit of inflammation of the joints, its true nature is frequently 
overlooked, and it is believed to have originated in cold and to be mere 
common bronchitis. No matter what be the cause of inflammation in a 
gouty habit — no matter what the organ attacked by the inflammation be — 
it almost invariably assumes the character of true gouty inflammation. If a 
gouty person sprains a toe or an ankle, matters, after progressing for a 
time in the ordinary way, are sure in the end to exhibit a change of cha- 
racter ; and the inflamed parts are observed either to grow unexpectedly 
worse, or to become stationary, at a time when a speedy termination of 
the local affection seemed approaching. This is owing to its being now 
modified by the constitutional tendency to gout, which localises itself in 
the affected part. Precisely the same relations may be often observed 
between common bronchitis, produced by cold in a gouty habit, and the 
gouty bronchitis it indirectly produces. Gouty bronchitis often becomes 
chronic, continuing until it is relieved by a regular fit of the gout in the 
extremities. 

The fifth species of pulmonary irritation, in which the source of the dis- 
ease is more or less obscure, is that which is connected with the scorbutic 
diathesis. It is important to be aware of this, particularly for those who 
have charge of the health of the poorer classes, which is almost of more 
value than that of the rich, for on it their labour and their means of sup- 
port depend. Among the poor, particularly in cities where the majority 
live on provisions not sufficiently nutritious, the scorbutic diathesis is 
very prevalent. It manifests itself either in the form of purpura, or in 
tendencies to hemorrhage from the nose, stomach, bowels, and bladder. 
It sometimes attacks the lungs, producing irritation of the bronchial mu- 
cous membrane, with cough and spitting of blood, and occasionally gives 
rise to pulmonary apoplexy. It is evident that pulmonic cases of this 
nature, originating in a scorbutic diathesis produced by confined air, 
damp lodging, and insufficient diet, will require a treatment peculiar to 
themselves, both during the attack and during convalescence. 

The last source of pulmonary irritation, to which 1 shall direct your at- 
tention, is that which proceeds from scrofula. You all know that scrofula 
has a tendency to attack every tissue in the body, but you may not per- 
haps be aware that it may affect those tissues in very different ways, and 
that scrofulous irritation may manifest itself in various forms, from the 
most trifling and transitory to the most extensive and permanent. I 
recollect a case I attended with Dr. Jacob, in which this fact struck me 
very forcibly. A fine boy, of high complexion, precocious intellect, and 
other marks of the scrofulous diathesis, got an attack of scrofulous oph- 
thalmia of an intense character, and it required all the skill and ingenuity 
of Dr. Jacob to save him from blindness. During the period of our at- 
tendance, his brother (who was also of a strumous habit) began to com- 
plain of parts of his arm being sometimes a little sore. This circumstance 
attracted my attention, and on examination I found that several circular 
diffused swellings, of various sizes, often equaling half a crown in dia- 
meter, had successively appeared on different parts of his extremities and 
body. They evidently depended on inflammation of the subcutaneous 
cellular tissue, and exhibited a remarkable example of a most transitory 
local affection, produced by a constitutional cause — for these swellings 



PLEURISY. 221 

arose, arrived at their acme, and subsided in the space of ten or twelve 
hours: they constituted, in truth, the first efforts of the scrofulous dia- 
thesis to localise itself, and, after a few weeks continuance, they were 
replaced by distinct and fixed scrofulous inflammation of the metatarsal 
bones. 

Here was a very curious and instructive fact. A boy, evidently of a 
scrofulous diathesis, has circumscribed tumours, which arise, come to 
maturity of irritation, and subside in the course of a few hours. In some 
weeks afterwards, scrofulous irritation, in a decided and permanent form, 
fixes itself in the foot, producing inflammation and ulceration. From 
this it may be inferred, that scrofula (for in this case lam firmly convinced 
these tumours were connected with strumous diathesis) may attack parts 
not only in its more permanent and destructive forms, but also in a manner 
so trifling and so transitory as to subside in a few hours, and leave no 
trace of its existence. The inferences deducible from this fact are numerous 
and important ; for if the scrofula may thus produce an acute and transi- 
tory inflammation of the subcutaneous cellular tissue, surely it may occa- 
sionally give rise to somewhat similar affections of internal organs — as the 
bowels, the lungs, &c. — and thus may occasion an acute bronchitis, a 
pneumonia, or an inflammation of the mucous membrane of the intestines, 
totally independent of the operation of cold, or the usual causes of such 
affections. It has been too much the custom only to refer chronic and 
fixed local inflammations to the agency of constitutional causes. The 
example before us proves that even the most transitory may have this 
origin. 

Scrofulous irritation may affect either the lining membrane or the paren- 
chyma of the lung — giving rise in the one case to scrofulous bronchitis, 
in the other to scrofulous pneumonia ; two affections which may exist 
separately or combined, and either of which may prove fatal, with or 
without the development of tubercles in the lungs. Tubercles have, as I 
have elsewhere proved, too exclusively engrossed the attention of those 
who have investigated the pathology of phthisis ; they are a very frequent 
product of the scrofulous diathesis, but the scrofulous bronchitis and 
scrofulous pneumonia are still more frequent and more important, and do 
not, as is falsely supposed, depend upon the presence of tubercles in the 
lungs. The pneumonia, the bronchitis, and the tubercles, where they 
occur together, are all produced by one common cause — scrofula. Of 
this more hereafter. 



LECTURE XXI. 

Gangrene and Pleuritis. 



I have here the lungs of a patient who died yesterday in the fever ward, 
and to whose case I have frequently directed your attention. They pre- 
sent some pathological phenomena of considerable interest, and I advise 
you to examine them carefully after lecture. 

The patient, who was advanced in life and of a feeble constitution, had 
been ill for a week before his admission, with symptoms of dyspnoea, 



222 CLINICAL MEDICINE. 

cough, and pain in the left side, which came on shortly after his recovery 
from an attack of fever. On examining him the morning after his admis- 
sion, we found the inferior part of the left lung dull on percussion, the 
dulness extending much higher up posteriorly than anteriorly. On 
applying the stethoscope, we observed that, over a space about the 
size of two palms, no sound, morbid or otherwise, could be heard ; but 
above the line which bounded this space there were crepitating rales and 
bronchial respiration. We had, therefore, a two-fold affection of the 
lung, pleuritis, as indicated by the pain in the side, dulness on percus- 
sion, and absence of all sound over a certain portion of the chest ; and 
pneumonia, as indicated by cough and expectoration of viscid sputa, 
tinged with blood, dulness of sound on percussion, bronchial respiration, 
and crepitating rales. It is unnecessary for me to recapitulate all his 
symptoms, as I have, while visiting the wards, mentioned them in detail, 
and I shall merely state that our examination showed that this man, in 
the first place, was labouring under pleuritis, and that it was of that kind 
which is called dry pleurisy, and where there is no tendency to consider- 
able effusion ; and, in the next place, that he had pneumonia of the 
inferior lobe of the left lung, extending up into the middle lobe poste- 
riorly. You recollect that, at the time of our examination, I marked on 
his skin with a pen the extent of the pleuritic inflammation as well as of 
the pneumonia, and you will find, by examining this lung, 1 that my diag- 
nosis was correct. You observe the pleura presenting, over its inferior 
part, latterly and posteriorly, an effusion of lymph, with a very small 
quantity of sero-purulent fluid ; and here is the seat of pneumonia, which 
occupied precisely the portion I pointed out and no more. 

With respect to treatment, it was antiphlogistic, pushed as far as the ad- 
vanced stage of the disease, and the age and debility of the patient per- 
mitted. He was leeched and blistered, and this was immediately followed 
by the use of calomel and opium, and the application of mercurial oint- 
ment over the affected portion of the chest. This treatment appeared to 
check the disease and stop the progress of disorganization in the lung, at 
least it certainly arrested the pleuritis. The pulse became more tran- 
quil, and what encouraged us to entertain some slight hopes was, that the 
difficulty of breathing subsided, and respiration became less frequent, al- 
though it was never reduced to any thing like the natural standard. I 
have already told you, that in studying acute and chronic affections of the 
chest, the two chief symptoms to be attended to, are the number of respi- 
rations which occur in a minute, and the amount of dyspnoea complained 
of by the patient. Here, though the respiration sank from forty to thirty, 
still they were nearly double the natural frequency ; and this, coupled with 
the age and debility of the patient, forbade us to hope for a cure. Though 
the pulse had become more tranquil, and the bloody expectoration had 
ceased, though dyspnoea was no longer complained of, and the frequency 
of respiration had become reduced, still the man's countenance exhibited 
strong marks of suffering and debility, and the stethoscope showed that 
the disease still continued, and that there was no tendency to resolution 
in the affected lung. Here the stethoscope was of great value. A person 
ignorant of its use, observing the tranquil state of the pulse, the diminu- 
tion in the frequency of respiration and the cessation of dyspnoea, might 
be led to believe that the man was getting better, and to pronounce that 
the period of convalescence was near. But the stethoscope told us that 



GANGRENE OF LUNG. 223 

the hepatization of the lung was not receding, and when we observed 
after a week, that it was still undiminished in extent, we were led to 
form an unfavourable prognosis. We knew that matters could not remain 
long in this state ; we knew that the disorganised lung acted as an irritant 
tending to keep up disease, and that the man was every moment liable 
to a new attack of inflammation. 

In the mean time the patient caught a fresh cold, from being exposed 
to the thorough air of our too well ventilated wards. This fell on his 
larynx, producing hoarseness, stridulous breathing, and copious expecto- 
ration. When an old person, reduced by some previous disease, catches 
cold, and gets, in consequence, a sudden and remarkable hoarseness, so 
that he can only speak in whispers ; when, in addition to this, he has 
cough, stridulous breathing, and copious muco-purulent expectoration, you 
may be sure that the case is a bad one, and the patient in most imminent 
danger. Inflammation of the larynx in children is, you all know, a vio- 
lent disease ; it terminates in an effusion of lymph which, if not prevented, 
or remedied, by the most prompt and decided measures, too often produces 
fatal obstruction to the entrance of air, and death from asphyxia. In the 
adult, laryngitis does not, except in a very few instances, cause an effusion 
of lymph ; still it is a severe disease, and well calculated to excite alarm. 
In the aged it is accompanipd by considerable fever, and, what you would 
suppose likely to give relief, copious expectoration, evidently derived from 
the larynx itself ; — and yet I do not recollect that I have ever seen an attack 
of this kind that did not terminate fatally. I have very recently visited a 
case of this description, which occurred in the person of an eminent 
country practitioner, who had just come to Dublin. He got an attack of 
cold followed by hoarseness, which went on for two or three days without 
being attended to, until one evening he suddenly became alarmingly ill, 
and was obliged to send for his friend Dr. Evanson, who prescribed and 
called on me the next day. I found him labouring under hoarse breath- 
ing, constant laryngeal cough, prostration of strength, and enormous muco- 
purulent expectoration. His pulse was very rapid, he complained much 
of oppression of the chest, and died the following night, more with symp- 
toms of exhaustion than of asphyxia. 

The symptoms of laryngitis, which arose thus suddenly in our patient, 
were quickly succeeded by others. On Saturday morning we found him 
much worse, his countenance was sunk and livid, and his breath had become 
exceedingly fetid. His expectoration also exhibited a very remarkable 
change; it was greenish, ichorous, and had a most intolerable fetor. He 
now began to manifest symptoms of awful prostration, his distress of re- 
spiration became intense, his eyes fixed, his extremities cold, and he ex- 
pired in about forty hours from the commencement of the attack. 

Here, gentlemen, a man, after fever, gets an attack of pleuro-pneumonia, 
this is relieved to a certain extent by treatment, but the hepatization re- 
mains unresolved. At the end of three weeks he gets an attack of laryn- 
gitis ; in addition to this, gangrene seizes on the diseased lung, and he 
sinks with great rapidity. Where gangrene attacks the limbs it may creep 
on slowly, and life may be prolonged for a considerable time, but when it 
fixes on internal organs its course is rapid, and generally proves fatal in 
a few days. In the lung, unless the patient's constitution is unimpaired 
and the disease limited, it will terminate quickly in death, and you have 
seen that in this case, it only lasted from Saturday until Monday morning, 



224 CLINICAL MEDICINE. 

that is to say about forty hours. After the acute stage of pneumonia had 
passed away, as denoted by the absence of fever and bloody sputa, and 
diminution of dyspnoea and frequency of respiration, the case assumes a 
chronic character, which continues for nearly a fortnight, and then a new 
order of symptoms appears, manifested by fetid breath and expectoration, 
sudden prostration of strength, hippocratic face, and cold extremities. 
Those who have watched this case must have been struck with these three 
remarkable stages : the first stage of inflammation, the succeeding one of 
chronic disease, and the termination in gangrene. It is not usual to find 
gangrene of the lung supervening on inflammation which has arrived at 
the chronic stage ; it is most commonly the result of acute inflammation of 
intense character, and comes on at a very early period of the disease. 

How are we to account for this sudden supervention of gangrene ? 
There was nothing in the nature of the pneumonic inflammation to dis- 
pose it to terminate in this way. It had lasted for three weeks, and had 
arrived at a stage in which inflammation very rarely assumes the gangre- 
nous character. To what, then, are we to attribute it ? Partly to the 
debility of the man's constitution, and partly to an erysipelatous tendency 
in the air, which is now very prevalent. Except there was something to 
dispose the lungs to gangrenous disease, as an enfeebled habit and vitiated 
quality of atmosphere, we could not, under the existing circumstances, 
have expected such a termination. That this view of the subject is cor- 
rect, is shown by the simultaneous occurrence of gangrene in another part, 
which had not been previously diseased, or subject to inflammation, ex- 
cept shortly before the man's death, — I allude to the larynx. If you ex- 
amine the larynx you will find the mucous membrane at the posterior 
surface, and where it invests the chordee vocales, destroyed by gangre- 
nous sloughing. You perceive, then, we had gangrene in the larynx and 
lung, simultaneously. The gangrene of the lung was not therefore attri- 
butable to the occurrence of local inflammation having a tendency to gan- 
grene, but dependent upon a constitutional affection produced by debility 
and a vitiated state of atmosphere. If this man had chanced to get a 
wound on any part of his body, I have no doubt but that it would have 
exhibited a gangrenous character, and, in the same way, if he happened 
to get inflammation of the bowels, it is most probable that this also would 
have ended in gangrene. I have frequently, in the advanced stage of 
fever, where the patient is much reduced, and where signs of a morbid 
condition of the fluids are present, seen gangrene occur simultaneously in 
various parts of the body. What I wish to impress on you is, that though 
the inflammation of the lungs ended suddenly in gangrene, it was not in 
consequence of the inflammation having in itself any such tendency, but 
in consequence of a change produced in the man's constitution by atmo- 
spheric influence, and which was favoured by his advanced age and great 
debility. 

The inference to be drawn from the sudden occurrence of gangrene in 
this case is, that it does not depend merely on violence of inflammation. 
At one time pathologists were inclined to believe that gangrene was in- 
variably the result of excessive inflammation, or at least of inflammatory 
action disproportioned to the vitality of the parts attacked, and that it was 
possible to prevent any inflammation from ending in gangrene by prompt 
and active treatment. But there are certain states of the constitution which 
have a tendency to convert every form of inflammation into gangrene, 



PLEURISY. 225 

and that wholly independent of the violence of the local inflammatory 
action. Thus, a person reduced by fever, small-pox, or malignant scar- 
latina, becomes liable to be attacked with gangrene in various parts of 
the body from the slightest causes. In all parts which are exposed to 
any degree of pressure, you will, under such circumstances, have gan- 
grenous sores formed ; and, even in parts where no degree of pressure 
has been exercised, sphacelus is not unfrequently produced, as we see in 
many cases of confluent small-pox, and in the mortification of the pudenda 
in female children, which sometimes occurs in bad measles. In such in- 
stances, gangrene is not preceded by symptoms of inflammatory action ; 
and, in the present case, it is very probable that no inflammation of the 
lung, properly so called, preceded the gangrenous affection which termi- 
nated life. 

Permit me now to direct your attention to the case of a man named T. 
Kelly, who lies in the upper fever ward, and has been under the care of 
Mr. Knott. He is at present labouring under an attack of pleuritis and 
pneumonia, each modifying the other — the pleuritis bein£ here also of that 
nature which is, by contra-distinction, termed dry. A few particulars in 
this case demand our notice. In the first place, from looking at this man 
and examining his pulse, you would never suppose that he was labouring 
under a formidable disease. A careless observer, finding the pulse to be 
soft, regular, and only seventy-two in a minute — that respiration was 
tolerably free, and the skin cool — might here very easily overlook the 
true nature of the disease, and say this man Las no fever, no inflammation 
of any internal organ. Yet a careful examination shows that the right 
lung and pleura are extensively engaged. In the next place, we find 
that the pleuro-pneumonia has attacked the upper part of lung instead of 
the lower. Pneumonia has a great tendency to attack the lower and 
posterior parts of the lung ; indeed, so frequently do we meet it in this 
situation, that we look upon its occurrence in the upper part of the lung 
as a rare exception to a general rule. The third point connected with 
this case is, that, though the patient is labouring under pleuritis and 
pneumonia, his blood does not exhibit the slightest symptom of being 
affected by this combination of violent inflammations. When drawn from 
the arm, it separated very imperfectly into crassamentum and serum, and 
there was no deposition of that bully coat which has been so often noticed 
by our ancestors, as occurring in pleuritis, and hence termed crusta pleu- 
ritica. Here, from observing that there was no perfect formation of coa- 
gulum — no cupped or buffed appearance in the blood, and that the pulse 
was soft and regular — some persons would have argued that no inflamma- 
tion was present ; but how false and dangerous such a conclusion would 
be, any one may convince himself by making a careful stethoscopic ex- 
amination. The fourth point (which was first observed by Mr. Knott) is, 
that there is a considerable disproportion in the sides of the chest : the 
right side measuring two inches and a half more than the left. Now, 
there must be some cause for this ; and as the man has pleuritis on this 
side, it would be natural to infer that there is a considerable effusion of 
fluid in the cavity of the pleura, and that the dilatation of the side is pro- 
duced by empyema. There are some circumstances, however, in this 
case which forbid us to adopt such a conclusion. In the first place, this 
great increase of size in one side of the chest would indicate a very con- 
siderable effusion. By empyema, I do not mean the effusion of a quan- 
16 



226 CLINICAL MEDICINE. 

tity of lymph, which does not push back the lung more than a line, but 
an effusion of fluids of various densities, in different patients, and in large 
quantity, exercising very considerable pressure on the lung, and pushing 
it back towards its root. There are two circumstances in this case which 
should be attended to ; first, the man is a labourer, and in such persons 
the chest, measured across the pectoral muscles, is always found to be on 
the right side half an inch, and sometimes nearly an inch, larger than it 
is on the left. This is accounted for by the increased development of the 
muscles of the right side from constant use. In the next place, we find 
that this man has not only pneumonia and pleuritis, but also a tendency 
to superficial inflammation occupying the parietes and integuments of the 
chest, as indicated by a feeling of pain and soreness in various regions of 
that side, but particularly at the lower part, where the sound is clear on 
percussion. Now, where the sound is clear on percussion, you are aware 
that no effusion of fluid exists. The fact is, that, in addition to pleuritis 
and pneumonia, the man is labouring under pleurodynia, with a tendency 
to inflammation in the superficial parts of the chest. Under these circum- 
stances, we should not be surprised to find some edema of the parts ; and 
here we have a second cause for the greater measurement of the right side 
of the chest. 

These are the only points connected with this case to which I shall 
advert at present, except to mention that the treatment was obviously indi- 
cated to be antiphlogistic. You might perhaps thinkthat in treating thisman 
it was a matter of indifference whether you had recourse to tartar emetic, 
either alone or in combination with nitrate of potash, or to calomel and 
opium ; but you may lay it down as a rule now firmly established, that in 
cases like this, the mercurial plan answers much better than tartar emetic. 
After bleeding this man, then, we gave him mercury in such doses as to 
affect his system as rapidly as possible, and we followed up our general 
means of depletion by the application of leeches, which, in all inflamma- 
tory affections of the chest, are indicated in proportion to the pain and ten- 
derness of the chest complained of by the patient. Indeed, something simi- 
lar must guide us in judging how far we are likely to procure relief, in 
cases of inflammation of any internal organs, by means of the application 
of leeches to the surface over the organ affected. No good is ever obtained 
by their application, unless tenderness or soreness on pressure be distinctly 
observable, and the relief is always proportioned to the diminution of this 
tenderness where it existed ; where it does not exist, the application of 
leeches only leads to loss of time, and we must employ other remedies in 
such cases.* 

There is another symptom in this case which might deceive you into 
the belief that empyema is present ; the motions of the right side of the 
chest are much more limited than those of the left. When you look at 
him stripped, you perceive an obvious difference between the respiratory 



* [Cups are almost always a better remedy than leeches in the treat- 
ment of inflammatory affections of the chest. In fact, leeches are pro- 
cured with so much difficulty by physicians in the country, and are so 
often bad, or at least indifferent, that cups should always be substituted 
for them when practicable to do so. In pleurisy, however, it is not a 
simple substitution of a bad for a good remedy, — cups are more efficacious 
as well as much more readily applied. — W. W. G.] 



PNEUMONIA. 227 

motions on each side ; the motions of the unaffected are free, and much 
more extensive than those of the diseased side. Now, generally speak- 
ing, this is a symptom commonly observed in empyema and a few other 
diseases. It may also exist where there is extensive hepatization of one 
lung, for, in proportion to the impossibility of air entering the diseased 
lung, will the motions of the corresponding side of the chest be dimi- 
nished. How are we to account for it in this man's case ? The pneu- 
monia is not extensive enough to cause it, and we have no evidence of 
the existence of any effusion into the pleural sac sufficient to explain it. 
The only way we can account for it is by recollecting that the man has 
pleurodynia ; and, as every attempt at dilating the chest gives him pain, 
he endeavours to curtail its motions on that side as much as he possibly 
can. This is a fact well worthy of notice. It exhibits to us a beautiful 
provision of nature, which enables a person, by an intense discharge of the 
respiratory function in one lung, to compensate himself for a limited and 
imperfect performance of it in that half of the chest where it is limited by 
pain, paralysis, or disorganization. 

As I am on the subject of pneumonia, it may be necessary to make a 
few remarks on some points connected with it, and first with respect to 
the expectoration. With the characters of true pneumonic sputa, I sup- 
pose, you are sufficiently acquainted ; you had many opportunities of 
examining the expectoration of the patient who died of gangrene of the 
lung at the time he was labouring under acute pneumonia, and while hepa- 
tization was still going on. 

Dr. Stokes does not consider the character of the sputa of much value 
in pneumonia. He says, " Although the sanguinolent and viscid charac- 
ter of the expectorated mucus is observed in many cases of pneumonia, 
yet it is any thing but constant. In fact pneumonia may occur with all 
varieties of expectoration, from a scanty and colourless mucus, to the most 
different characters of secretion. It often occurs without any character- 
istic expectoration, and may thus pass even to its advanced stages. Gene- 
rally speaking it may be said that the crachats rouilles of the French, are 
found in the more active cases of pneumonia, which occur in robust habits; 
but 1 am convinced that in a large proportion of the hospital patients, in 
whom the disease occurs in feeble constitutions, in the child, or as a com- 
plication or sequel to fever, the appearance of the sputa has little value." 
— Treatise on Diseases of the Chest, page 320. 

But I wish to observe — and I beg you will impress this on your minds 
— that there may be cases of extensive pneumonia without any expectoration 
from the commencement of the disease to the period of complete resolution. 
A case occurred in this hospital, of a young woman, named Mary Nowlan, 
who had half one lung and the lower third of the other hepatised during 
a severe attack of pneumonia, and yet it was not accompanied at its com- 
mencement by expectoration, there was no expectoration during its con- 
tinuance, and resolution went on, and the lung was restored to its healthy 
condition without any expectoration. She remained in the hospital for 
two months, the lung being extensively engaged ; and during this time 
she was carefully watched, but we never could discover any thing like 
sputa from the beginning to the end of the disease. We have lately had 
under our observation a case of pneumonia after measles, in which a 
similar absence of the expectoration was observed. This is a very sin- 
gular but instructive case. Another fact with regard to expectoration. 



228 CLINICAL MEDICINE. 

A man may get an attack of pneumonia, and, in consequence of the rush 
of blood which accompanies the first access of inflammatory action in the 
lung, may have at the beginning some bloody expectoration, but after a 
day or two this subsides ; and though the lung is considerably affected, 
the patient may not have any expectoration whatever throughout the 
whole course of the disease up to the period of total resolution. I have 
seen this occurrence most distinctly marked in a case which I attended 
with Sir Henry Marsh. A gentleman, who had got an attack .of acute 
pneumonia, had bloody expectoration for the first and second day, but 
on the third, when I saw him, it had ceased, and all expectoration con- 
tinued absent for five weeks, at the end of which he completely recovered. 
He was an intelligent and scientific man — knew well what was the matter 
with him, and entertained the old notion that all inflammatory affections 
of the lungs resolve themselves by expectoration. Hence he looked day 
and night for its occurrence with considerable anxiety, but not the least 
sign of sputa appeared. In this case the hepatization, which was very 
extensive, became completely resolved in the course of five weeks, and 
yet it is a singular fact that there was no expectoration whatever, from 
the commencement of resolution to its termination. Hence you may per- 
ceive, that in pneumonia the sputa may be absent from the beginning to 
the end of the disease ; and that though the hepatization may be very 
extensive, still resolution will occur without the slightest expectoration. 
Again, inflammation may attack a considerable portion of the lung, and 
the patient may have bloody expectoration for the first two or three days, 
or during the stage of congestion ; this may cease altogether, and the 
patient have no sign of sputa of any description up to the period of com- 
plete resolution. These are, no doubt, rare exceptions to the general 
law which regulates the course of pneumonic inflammation, in which we 
have sputa of one kind or other at every period of the disease ; but they 
possess a considerable degree of interest, and it is of some importance to 
be acquainted with them. 

Allow me to repeat here an observation I have already made. The 
lung becomes attacked by inflammation, this goes on to hepatization, that 
is, a certain portion of the pulmonary tissue which had been before per- 
vious, becomes impervious ; instead of being a soft, elastic, crepitating, 
sponge-like body, it becomes solid, inelastic, and very like that organ from 
which this condition derives its name, the liver. One of the most curious 
things, the knowledge of which we have arrived at by the discovery of 
the stethoscope, is, that not only small, but even very extensive portions 
of the lung may become thus solidified and altered in their texture, so 
that a return to the normal condition would seem almost impossible, and 
yet we know that a person may have nearly tw T o-thirds of one lung reduced 
to this state of solidification, and still become afterwards as healthy as 
ever. Now, if you read Laennec's admirable remarks on pneumonia, 
and other treatises on the same subject, you will find that the circum- 
stances which indicate the resolution of pneumonia, are sputa of a cer- 
tain character, and the reappearance of crepitus. I need not repeat here 
what I suppose you are all aware of, that crepitus commences before 
hepatization, ceases on its appearance, and returns again when resolution 
takes place. The latter kind is what has been termed by Laennec, crepitus 
redux. The crepitus of resolution differs, however, from that heard in 
the earlier stages, in these particulars, viz., its bubbles are much larger 



HAEMOPTYSIS. 229 

and raoister, and it can be heard during the whole of the inspiration, and 
in a diminished degree during expiration. But in the other case the first 
part of the inspiration is pure, and the rale only appears at the termination 
of the effort, and is of an exceedingly fine and dry character. Nature 
accomplishes the resolution of pneumonia not only by absorption of those 
particles which the process of morbid action has deposited in the tissue 
of the lung, but by secretion into the air-cells and minute bronchial 
tubes, and it is the presence of this secretion which gives rise to the 
crepitus redux. Now, the observations which I have made with respect 
to the total absence of expectoration in some cases of pneumonia, apply 
here also ; for where all sputa are absent, where there is no expectoration 
from the beginning to the end of the disease, you can have no crepitus 
redux. The fact which I wish to impress on your attention is, that in 
some cases of pneumonia expectoration may be completely absent ; here 
the crepitus redux is never heard. Thus, in the case of Mary Nowlan, 
resolution went on to the re-establishment of the healthy and normal con- 
dition of the lung, without the slightest crepitus being heard. The same 
thing has been observed in two or three cases by my friend Dr. Dwyer. 
It is not necessary for the resolution of hepatization, that there should be 
increased excretion into the bronchial tubes, during the time nature is 
employed in absorbing the matter deposited in the lung. In the ordinary 
way it is removed partly by absorption and partly by excretion into the bron- 
chial tubes. Sometimes, however, interstitial absorption alone seems to be 
sufficient for this purpose, and the cases I have mentioned prove that it is 
in the power of nature to remove the morbid product in this way, without 
calling in the aid of the bronchial tubes. I may, however, remark that 
such cases are rare, and that resolution proceeds much more slowly than 
where free expectoration is present. 



LECTURE XXII. 



Haemoptysis — Pulmonary Apoplexy — Phthisis — Treatment of Haemoptysis — Remarkable 

instances of recovery. 

Gentlemen, — We shall now commence the consideration of haemoptysis. 
Let us first consider it with reference to the different parts of the vascular 
tissue of the lungs, which are engaged in its production, and afterwards 
speak more accurately of the symptoms attendant on each. It may be 
well to commence with the source of haemoptysis, because there are some 
misconceptions respecting it, and I do not think that it has been clearly 
laid down in books written on this subject ; I shall, therefore, devote 
more time to the consideration of some points of the morbid anatomy of 
this disease than I usually do in a clinical lecture. Other circumstances, 
which you will find sufficiently described in written treatises, I shall pass 
over briefly. In order to comprehend fully the peculiarities of haemop- 
tysis, it is necessary that you should be intimately acquainted with the 
circulation of the lungs. Here you have not only the simple circulation, 
as in other parts, but, as in the liver, we have the vena porta for the form- 
ation of bile, and the hepatic artery for nutrition, so in the lungs we have 
the pulmonary arteries carrying blood, which is to be aerated, while the 



230 CLINICAL MEDICINE. 

bronchial arteries carry blood, for the support and reparation of the pul- 
monary substance. You are aware, gentlemen, that it has been lately 
shown that the lung is but a large gland, whose ducts are the bronchial 
tubes, and whose secreting surface is that of the air-cells. There is this 
difference in the sources from which blood is furnished to the lungs : the 
bronchial artery is small, and its blood red ; the pulmonary artery im- 
mensely large, and carrying dark blood, which is to be aerated ; the bron- 
chial arteries follow the course of the bronchial tubes, interlace with and 
ramify over them, enter them, and are distributed in great profusion to 
their mucous lining. On the inflammatory action of these arteries, the 
redness and injection of the mucous membrane, observed in cases of bron- 
chitis, depends. The bronchial arteries, also, send branches to the cel- 
lular membrane, connecting the air-cells, and to the surface of the lungs, 
but it is for the mucous membrane, lining the bronchial tubes, the greater 
part of their blood is destined.* You know, gentlemen, that if we exa- 
mine the structure of the lungs, besides their vascular tissue, we observe 
they consist chiefly of ramifications of the bronchial tubes leading to air- 
cells. These cells may be represented as so many minute vesicles, each 
communicating by a minute aperture with an extremely small ramification 
derived from the bronchi. This fact has been show T n and described by 
Reisseisen. The vesicles which are placed at the extremities of these 
minute branches, and the branches themselves, present certain differences, 
the vesicles presenting a greater degree of tenuity, and a strong resem- 
blance to serous membrane. These distinctions between the structure of 
the air-cells and that of the bronchial tubes, cannot be easily recognised 
in the very minute tubes of the bronchial ramifications, but become more 
evident as we ascend towards the larger bronchi. The use of the air vesi- 
cles is to aerate the blood in the lungs, and it is on the parietes of those vesi- 
cles or cells, the ultimate branches of the pulmonary arteries are distributed. 
When we come to speak of discharge of blood from the lungs, and to 
consider the phenomena it presents, we find that it may take place from 
the minute extremities of the bronchial, or of the pulmonary vessels. The 
seats of the ultimate ramifications, as I have before mentioned, are com- 
pletely distinct, and it is important to recollect that they are so. Inject 
the bronchial arteries with as much care as you possibly can, and I say 
you cannot, by doing so, inject the vessels which ramify on the air-cells, 
nor can you, on the other hand, inject the vessels which are distributed 
to the mucous membrane of the bronchial tubes from the pulmonary arte- 
ries. Of this I am perfectly sure, for I have tried the experiment myself 
unsuccessfully, and have examined w T ith the greatest care the beautiful 
preparations in the museum of Dr. Townsend, and neither he nor Dr. 
Houston could show me one instance of the bronchial mucous membrane 
having been injected from the pulmonary artery. Even the finest injec- 
tions, used by Dr. Houston, at my request, in the lungs of dogs, failed to 
effect what would indeed be easy of accomplishment, if engorgement of 
the system of the pulmonary artery was capable of producing bronchial 
hemorrhage. There is, to be sure, a system of capillary vessels in the 

* Reisseisen remarks, that by far the greater portion of this blood is returned, not by the 
bronchial veins to the right side of the heart, but by the pulmonary veins to the left side. Is 
this peculiarity owing to this blood being dissimilar to other venous blood, in consequence of 
being ae rated in the bronchial tubes 1 or is it because it may be mixed with impunity with the 
great mass of aerated blood returning from the lung. 



HEMOPTYSIS. 231 

lung, through the medium of which an indirect communication is estab- 
lished between the bronchial and pulmonary arteries and the pulmonary 
veins. Dr. Law, of this city, in the article " Haemoptysis, " in the Cyclo- 
paedia of Practical Medicine, has handled the subject of the relative distri- 
bution of the vessels in the lungs with his usual ability. I cannot, how- 
ever, see that Reisseisen, whom he follows, justifies him in considering 
hemorrhage from the bronchial tubes as a consequence of hemorrhagic 
engorgement of the system of the pulmonary artery. " We readily 
account for its frequency," says Dr. Law, " by the facility with which an 
injection is found to pass from the pulmonary into the bronchial artery." 
Reisseisen, it is true, points out that the bronchial and pulmonary arteries 
anastomose with the same system of capillaries on the surface copiously, 
and more sparingly in the cellular texture of the lung, but his description 
likewise proves, that the bronchial mucous membrane is exclusively sup- 
plied with red blood bj the bronchial arteries. It is indeed true, that we 
can force injection from the pulmonary artery into the bronchial tubes, but 
even in such cases, the bronchial mucous surface is uninjected, and the 
injection finds its way therefrom into those tubes by other channels than 
the bronchial artery, or its ramifications, which would indeed be a retro- 
grade course. I am, therefore, of opinion, from the reasons above stated, 
that when haemoptysis, from the engorgement of the system of the pulmo- 
nary artery, takes place, it is in consequence of the direct effusion of blood 
from the branches of the pulmonary artery, which ramify on the air-cells, 
and that the blood expectorated on such occasions has nothing to do with 
the bronchial mucous membrane, or bronchial arteries. 

When we recollect the peculiar texture of the lungs, and the quantity 
of blood which is sent through them at each stroke of the heart ; when we 
consider the excessive tenuity and delicate structure of the air-cells, which, 
when the lung is inflated by inspiration (and that is the very moment 
when most blood rushes through it), imparts to the touch the feeling of an 
elastic but almost gauze-like and cellular substance, we are surprised to 
find that cases of spitting of blood are not much more frequent. The lung, 
however, is an organ so important to life, that if there w T as much danger 
of hemorrhage from its tissue, it would be a greater error in our structure 
than nature was likely to commit. Cases of this kind are comparatively 
rare, and we do not meet with them every day in our hospitals. Compare 
with the patients afflicted with dangerous and copious haemoptysis the 
number of cases of bleeding from the nose, haematemesis, discharges of 
blood from the bowels, and hemorrhage in general, and you will find that 
the lungs are not more liable than other parts to sanguineous effusions. 

When speaking of the vascular arrangements of the lungs, we mentioned 
that the bronchial mucous surface is supplied with blood from the bron- 
chial arteries, and the air-cells from the pulmonary. Hence we can divide 
these discharges into two kinds, those which come from the pulmonary, 
and those which are derived from the bronchial arteries ; and these will 
be found to be distinct, not only in their pathology, but also in their cha- 
racters and the symptoms by which they are attended. We shall go through 
this minutely. Let us suppose that the pulmonary artery is disposed to 
bleed, what will take place ? Its ultimate ramifications, which are distri- 
buted over the air-cells, get a hemorrhagic tendency, and blood escapes 
from them in two different directions, into the air-cells, and into the cellular 
tissue which connects them. That portion of blood which gets into the air- 



232 CLINICAL MEDICINE. 

cells will also get into the bronchial tubes, and maybe spit up. That portion 
which gets into the intervesicular cellular tissue has no such exit : there 
it must remain and become coagulated and solidified. Now, as either of 
those effects may happen, we may have spitting of blood , or else effusion into 
the cellular texture, without haemoptysis.* It is to the union of these two 
diseases the term pulmonary apoplexy has been applied, in which we have 
blood effused into the cavity of the air-cells, and outside their cavity into the 
cellular tissue. Now, what is the result of sanguineous effusion from the pul- 
monary branches ? In the first place the blood is black, as you can perceive 
when it is spit up. It is also clear, that if this blood be detained for some 
time in the air-cells and bronchial tubes, it will become coagulated, and 
be spit up in clots. Many of the worst cases of spitting of blood are at- 
tended with this symptom ; and it is not a mistake to suppose, as you see 
it mentioned in books, that blood expectorated from the lungs should be 
florid and frothy. You are told, gravely, that you can distinguish blood 
discharged from the stomach from that which is discharged from the lungs, 
by the difference of its colour, consistence, and the presence or absence of 
air bubbles. No, gentlemen, you cannot. If you see blood spit up which 
is dark and coagulated, and, from stethoscopic examination, have reason 
to think that it comes from the lungs, you will be convinced that the effu- 
sion is from the pulmonary artery. I do not mean to say, that when blood 
comes from the pulmonary artery it is always black and clotted ; but I as- 
sert, that it is so in a great majority of cases ; and in many cases of pneu- 
monia, we find the sputa partake more of the venous than the arterial cha- 
racter, a circumstance which indicates its formidable source. It is obvi- 
ous, that the blood spit up in those cases may also have a florid tinge 
where it has been imperfectly aerated, by the imperfect action of air bub- 
bling through it before it is expectorated.! 

* To establish the correctness of this explanation, it is necessary we should see the occur- 
rence of pulmonary apoplexy without haemoptysis, and here I feel happy in being able to quote 
a case which was witnessed by three accurate observers — Dr. J. 0. Ferguson, by whom it is 
related, Dr. Law, and Dr. Hunt, of this city. The case is as follows : A man named M'Oleary, 
of intemperate habits, who used to apply at the L'oles Lane Dispensary, for purgative pills, 
appeared there June 29, 1829, complaining of coetiveness, severe cough, oppression of chest, 
and expectoration tinged with blood since the day before, pulse 90, feeble. Two days after, 
while in the act of putting on his shoes, he complained to his wife of loss of vision, seemed to 
faint, and died without a struggle. He had expectorated no blood for fourteen hours before 
death, nor in the agony -was there any escape of blood from the mouth or nares, -which might 
lead to a suspicion of the real seat of disorganization. Post-mortem. The left pleural sac 
contained about three quarts of blood ; the serum supernatant to a great degree, as in blood 
allowed to stand after venesection, and the clot in considerable quantity, but very soft, occu- 
pying the most dependent portion of the cavity. The superior lobe of the left lung was one 
mass of the most perfect pulmonary apoplexy ; the structure of the lung seeming to be abso- 
lutely broken up by the excessive effusion of blood into it. The appearance differed from that 
which Laennec has observed in similar cases, so far from resembling the firmness of an hepa- 
tised lung, the apoplectic mass was exceedingly soft and flabby, much more like a clot of blood. 
There was no rupture of any large vessel." — Dublin Medical Transactions. New series, 
page 13. 

f This subject requires further investigation ; for not only is it possible, as is stated in the 
text, that black blood may be changed in colour, after effusion into the bronchial tubes, by the 
rapid bubbling of air through it, but also it is extremely probable that if arterial blood oozes out 
very slowly from the bronchial surfaces, and remains for any considerable length of time in the 
air-passages, mixed with their mucous secretion, it may, before it is expectorated, change its hue, 
and become dark, as happens where red blood is long exposed to the action of the secretions 
of the alimentary canal, e. g. in melaena. These views have been since confirmed by the ex- 
periments of physiologists, as the following extract will show: 

" When arterial blood is kept at rest in a living vessel, it gradually acquires the properties 
of venous blood, as may be seen on slackening a tourniquet after an amputation when the first 



HAEMOPTYSIS. 233 

There are some hemorrhages, also, from the bronchial artery, which 
are very copious ; but, generally speaking, where there is much cough, 
constriction of the chest, and fever, it is the bronchial mucous surface 
which is affected ; and the spitting of blood which, in such cases, comes 
from the bronchial arteries, is but scanty, and is seldom dangerous. The 
blood will be found to be effused from small spots, as in epistaxis, and 
the quantity is generally small. You will, however, sometimes find an 
instance of a person spitting up, very copiously, blood of an arterial colour ; 
for it must be borne in mind, that a very small surface of mucous mem- 
brane may often bleed most copiously, as is seen in some cases of epis- 
taxis, when the blood issues from an insulated and small spot. Such 
cases of copious bronchial hemorrhage occur occasionally, are unconnected 
with bronchitis, and depend on some peculiar hemorrhagic tendency. 

We have thus drawn a distinction between these two kinds of hemor- 
rhage ; let us trace it further. Suppose you have a case where blood is 
effused into the cellular tissue of the lungs; the blood so effused is imme- 
diately submitted to a peculiar action of the animal economy. It is first, 
by coagulation, separated into two portions, serum and crassamentum. 
The serum is rapidly absorbed, and as soon as this is accomplished, the 
crassamentum becomes solidified, and remains there with its colouring 
matter, as you have it represented in this plate of Cruveilhier, where you 
perceive, as it were, balls in the substance of the lung, of a solid consist- 
ence and red colour, formed by the colouring matter and clot. The first 
effect of effusion of blood into the cellular tissue is a tendency to solidifi- 
cation, one chief consequence of this disease, which has not been noticed 
by those who have written on pulmonary apoplexy. Nature, gentlemen, 
is anxious to stop the effusion of blood, as, in this instance, it threatens 
that life which she watches over, at all times, with so much care. Now, 
what is the consequence of this solidification ? First, all the air-cells of 
the part are closed by the pressure of the coagulura, that portion of the 
lung which has been bleeding becomes impervious to the air, and this 
circumstance alone is sufficient to arrest the hemorrhage. And why is 
this the case ? Because the blood which flows through the pulmonary 
arteries cannot pass into the veins, unless in its passage it be aerated. 
It is its aeration, which, at the first moment when the infant respires, 
causes the blood to rush through the pulmonary vessels in ten times the 
quantity it did before birth. If you asphyxiate an animal, or by any 
means put a stop to the process of aeration, you will find that in propor- 
tion as the air in the lungs becomes deficient or impure, the blood ceases 
to pass from the right to the left cavities of the heart, because it cannot 
pursue its natural course unless it be properly aerated. Hence, when a 
part of the lung becomes impervious to the air, the passage of the blood, 
so far as that part is concerned, will cease, and consequently the tendency 
to hemorrhagic effusion.* You see, gentlemen, in this case, two causes 

blood that issues from the divided arteries is of a dark colour. If arterial blood is placed in 
vacuo, or is exposed tu nitrogen, hydrogen, or carbonic acid, it loses its florid hue. 

" Exiravasated arterial blood remains florid for several minutes ; after an interval it is 
found to have coagulated, and to have acquired a dark colour?' Maid's Physiology, p. 21. 
Fourth Edition. 

* By the passage of the blood is here only meant the rapid and unimpeded circulation from 
the pulmonary artery into the pulmonary veins, for it is evident that a part of the lung, imper- 
vious to the air, may be the seat of sanguineous engorgement, as happens in the posterior parts 
of the lungs of those who die after a long agony, or in the various stages of pneumonic engorge- 
ment and hepatization. 



234 CLINICAL MEDICINE. 

in operation to prevent effusion of blood, mechanical pressure, and such 
a state of that portion of the lung which had been bleeding, that less blood 
goes to it in consequence of its no longer performing its share of the re- 
spiratory function. 

A great deal has been written about the ulterior effects of blood thus 
effused. It is evident that when the effusion takes place into the air- 
cells, it may be spit up and produce no further harm ; and if the patient 
recovers without any effusion into the intervesicular tissue, there is no 
trace of the disease. The danger, therefore, arises from the quantity of 
blood poured into the cellular texture, which, by obliterating the air- 
cells (if the extent be considerable), may destroy the functions of the 
lungs, and in this way produce death, as you may have observed in the 
case of haemoptysis above stairs, where the cessation of the spitting of 
blood was a bad symptom. The disease was going on for some time, 
and not confined to any particular part, but extending over the whole of 
one of the lungs, and you can now conceive the reason of this man's 
death. It was because by effusion and solidification to a great extent he 
was deprived of the use of his lung. Yet you will find instances where 
a person has more than half the lung filled with a clot of this kind, and 
still survives ; and you may observe parallel cases in the prolonged life 
of some patients who labour under organic disease of the lungs. This is 
generally seen where the quantity of blood circulating in the whole system 
is small ; for when the power of aeration is diminished, it is necessary 
that the quantity of blood which passes through the lungs should be re- 
duced below its average amount, or its course will be arrested. 

Now, gentlemen, where we have solidification of the lung, and oblite- 
ration of the air-cells, from such effusions, what is the consequence ? 
Sometimes we have sudden death from dyspnoea, sometimes the fatal ter- 
mination is of a slow character. It is stated by some authors, that blood 
of this kind acts as a foreign body, as an irritant, and excites inflamma- 
tory action. Others say that the effused blood not only produces inflam- 
mation, but also gangrene and softening of the affected portion of lung. 
With respect to this, I may be permitted to express very strong doubts. 
We do not see effusions of blood in other parts of the body attended 
with such consequences. I would ask any one, who has seen a case of 
ecchymosis under the conjunctiva, where that membrane is raised high 
over the eyeball by an immense clot of blood, whether this clot, though 
in such close juxtaposition with an extremely sensitive organ, ever pro- 
duces inflammation ? How often have we seen blood effused into cellu- 
lar tissue from wounds, or contusions, remain quietly in its new situation, 
and be absorbed, without producing any inflammation ? But, with respect 
to this question, the admission of all pathologists, that many such portions 
may exist in the lungs together, without the least solid appearance of 
inflammation in the pulmonary substance immediately around them, seems 
quite conclusive. Thus in Cruveilhier's plate, now before you, the sec- 
tion of the lung showed that the cells were uninflamed quite to the very 
edge of the various solidified portions, although they had existed for many 
days before death. Again : do we not know, that even in the brain 
itself, blood may be effused and sudden paralysis produced, and that the 
patient may quickly recover, and a clot remain in the cerebral substance 
without producing inflammation. It is true that blood effused into the 
lungs is, in many cases, attended by pneumonia, and that extravasations 



HEMOPTYSIS. 235 

in the brain are frequently accompanied by softening. This I do not 
deny ; but I think that both are simultaneous effects of the same cause, 
and that in the one case pneumonia and sanguineous effusion, and in the 
other, extravasation and ramollissement, are only different parts of the 
same process. 

If a person recovers after the discharge of a large quantity of blood 
into the lungs, what is the consequence ? If the constitution be sound, 
and the hemorrhagic tendency does not recur, it is probable that this por- 
tion maybe submitted to the action of absorption, and ultimately rendered 
healthy. This [ believe may happen, for the phenomena of absorbed 
hepatization in pneumonia gives it probability, though I have not seen 
it verified. I have, however, ascertained satisfactorily, that this portion of 
the lung may remain solid for a considerable length of lime, without pro- 
ducingany particular symptoms. Two cases of this condition of the lung, 
remaining in one instance for a year and a half, and in another for three 
years, without subjecting the patients to any inconvenience whatever, 
have come to my knowledge, and, after death (which was caused in each 
by a different disease), I have been able to detect those solidifications by 
dissection. It has been stated that persons who have portions of the 
lungs solidified, are liable to phthisis. Where scrofula exists, tubercles 
may be precipitated into suppuration from this cause ; but where the con- 
stitution is not scrofulous, the consumption which fellows solidification of 
the lung is certainly not tubercular. I remember having attended, some 
time ago, a young man who had an attack of pulmonary apoplexy, and 
who afterwards got all the symptoms of phthisis except diarrhoea ; I 
watched this case through all its stages, month after month. On examin- 
ing the lungs after death, I could not detect a single tubercle ; the matter 
was extensively diffused through the cellular tissue, constituting that dis- 
ease to which the name of suppurating pneumonia has been given. In 
the case of a young gentleman residing in Gardiner Street, who was 
attended by Mr. Colles, the symptoms above mentioned were present, 
and it was generally thought that he was dying of tubercular consumption. 
I was called in to see him, and, on inquiring into the history of the case, I 
gave it as my opinion, that it was not tubercular consumption, but exten- 
sive suppurating pneumonia, an opinion which was borne out by the ne- 
croscopic phenomena. You see, therefore, gentlemen, that a man may 
live for a considerable time with a portion of his lung solidified in conse- 
quence of this disease, or that he may get pneumonia, which may go on 
to interstitial suppuration, and present all the symptoms of tubercular con- 
sumption ; or, if his constitution be scrofulous, he may get true tubercular 
phthisis. It is obvious, that in a person whom this disease would render 
obnoxious to pneumonic inflammation, if scrofula exists, you will have the 
tubercular instead of the pneumonic action developed ; for in scrofulous 
habits you will find that every cause which produces irritation, or a ten- 
dency of blood to the chest, produces also a tendency to consumption. 
Dr. Stokes and I attended, some time since, a gentleman who had pleu- 
ritic effusion in the right side of the chest, with engorgement of the lungs 
and dyspneea. During the course of the disease he got tubercles, and 
where, do you think ? Not on the side where the pleuritic effusion 
existed, but in the upper part of the left lung. You should not be sur- 
prised at this ; it was a consequence of the disturbance of the respiratory 
functions, and you may be assured that every thing which deranges the 



236 CLINICAL MEDICINE. 

pulmonary circulation in scrofulous persons, has a strong tendency to the 
development of tubercles. 

There is a question in Laennec's work, to which Dr. Law has also 
alluded in his treatise on Haemoptysis, in which it is asked, can spitting of 
blood be considered as the cause of consumption ? To this I will answer, 
that I have seen more than one case of pulmonary apoplexy in which the 
patient died of the first attack, and yet not a single tubercle could be found 
in the lungs. It may certainly produce a tendency to consumption, but is 
not a necessary cause of it. The same may be said of bronchial haemop- 
tysis. Any one who has witnessed the dissections of the lungs of tuber- 
culated patients must have frequently observed, that tubercles are accom- 
panied by an inflamed state of the bronchial mucous membrane. It is 
notorious, also, that this state of the mucous lining, with the hard, dry 
cough which it occasions, is one" of the first symptoms of tubercles in the 
lung ; ana we therefore find, in many instances, that bronchial haemop- 
tysis is a consequence and not a cause of tubercle.* 

Having hitherto dwelt chiefly on the general pathology of haemoptysis, 
I shall make some additional observations on the causes of this disease, 
and then proceed to the treatment, without entering into an accurate de- 
scription of the particular symptoms, which you will find sufficiently de- 
tailed in the works of Mason, Good, Laennec, Mackintosh, and in the 
excellent article " Haemoptysis," in the Cyclopaedia of Practical Medicine , 
by Dr. Law, and the valuable essay of Dr. Townsend on Pulmonary Apo- 
plexy. You recollect I differed from Dr. Law, with respect to the source 
from which the blood is derived in bronchial hemorrhage. Dr. Law is of 
opinion, that any thing which produces engorgement of the system of the 
pulmonary artery, occasions hemorrhage from the bronchial tubes ; but 
this, for the reasons before stated to you, is impossible. I have also en- 
deavoured to explain to you the manner in which pulmonary Apoplexy 
may be followed by extensive disease of the lung, interstitial suppuration, 
and death ; or, on the other hand, how a coagulum may be formed in the 
substance of the lung, and the person affected remain in a state of perfect 
health. I have proved, from dissections, that after the lung has been 
solidified, in consequence of pulmonary engorgement, it may remain in 

* [There is no doubt that Dr. Graves is perfectly right in stating that 
haemoptysis is not a necessary cause of consumption. Phthisis, indeed, is 
more frequently a cause of the hemorrhage than an effect of it. In most 
cases, it would seem that the same morbid change in the lungs which 
favours the development of tubercles, renders them disposed to pour out 
a large quantity of blood, either under the influence of slight causes of 
hemorrhage, or when no obvious external cause can be discovered. Hae- 
moptysis is, however, an important diagnostic sign of consumption, be- 
cause it is known to be produced in patients who are labouring under 
confirmed phthisis, or at least a strong predisposition to it, oftener than in 
any other class of patients. At the same time it is not a necessary sign 
of phthisis, especially in women in whom an arrest of the catamenia often 
gives rise to abundant expectoration of blood. In men, Andral used to 
say that haemoptysis occurred in patients attacked with phthisis, or at least 
strongly threatened with it, four times out of five, but in women only 
twice out of three times. This is about the proportion of the cases. — 
W. W. G.] 



HEMOPTYSIS. 237 

that condition for years, or if a scrofulous diathesis exists, such an occur- 
rence may be followed by tubercular consumption. I have mentioned 
that kind of consumption supervening on effusion into the cellular tissue 
of the lung, where there is extensive interstitial suppuration, and not a 
single tubercle can be discovered. You will recollect my statement that 
I could adduce instances in which pulmonary effusion took place, and the 
clot remained in the cellular substance without producing any irritation, 
and that, on dissecting such lungs, J found those organs perfectly sound 
up to the limits of the clot, and this in cases where the effusion had ex- 
isted for several months.* Now if this remained in the substance of the 
lung, as a harmless body, for so long a space of time, 1 cannot conceive 
how a similar effusion could in any case become a stimulant. I differ 
also from those who think that the effused blood may become corrupted 
and a cause of gangrene. 

We will now proceed to the consideration of some of those constitu- 
tional tendencies, which render persons liable to spitting of blond. It has 
been frequently remarked, that bleeding from the nose, during the periods 
of infancy and adolescence, is a symptom of frequent recurrence in those 
who are obnoxious to this disease, and in such persons without anv appa- 
rent cause, and unaccompanied by any proper fever, the attack comes on 
with a hemorrhagic excitement of the circulation, sense of constriction in 
the chest, anxiety, dyspnoea, cough, and expectoration of blood, of an 
arterial colour and frothy appearance. As soon as the expectoration, 
which is sometimes copious, sometimes scanty, lakes place, the patient 
gets relief. There is not much preceding or following cough. Such are 
the characteristics of this hemorrhage, which does not prove the existence 
of tubercles, or engorgement of the system of the pulmonary artery, and 
has no more reference than epistaxis to disease of the lungs. I knew 
seven gentlemen of the same family, most of whom were in the army, and 
residing in different climates, who were all subject to sudden expectora- 
tions of blood, without any particular antecedent or subsequent cough, or 
other symptoms of chest disease. Now I need not tell you that as long 
as the hemorrhage preserves this character, and confines itself to the 
bronchial mucous membrane, there is very little mischief done. Persons 
thus affected will have repeated attacks of this kind, and though their 
lives are not the best, may attain a good old age. It is only when the 
extreme branches of the pulmonary artery take on the hemorrhagic action 
that danger is to be apprehended ; and so it was with one of the gentle- 
men just mentioned. He had, during a period of twenty years, many 
sudden and often violent attacks of haemoptysis, which never lasted more 
than a few days, and always subsided without leaving a trace behind. So 
long as the hemorrhage was bronchial, it was comparatively free from 
danger : at last its seat was changed ; it occupied the air-cells and inter- 
vesicular cellular tissue of the lungs, and he died of pulmonary apoplexy. 
When the latter takes place, you must be on your guard, for I have seen 
cases of melama, where the customary discharge of blood from the intes- 
tines was considerable, and instances of piles, where the bleeding from 

* It is not meant that the effused blood occupies the texture of the lung, without becoming 
organised. This is certainly not the case ; all I mean to assert is, that the portion ot the lung 
originally rendered solid by the clot, remains solid, in some cases, for a great length of time 
constituting an insulated mass impervious to the air its If. but not a source of irritation to the 
surrounding parts. 



238 * CLINICAL MEDICINE. 

the rectum was great, from being suddenly arrested, produce pulmonary 
apoplexy and death. In such patients, gentlemen, nature attempts to 
establish a vicarious discharge for that which has been suppressed. This 
is a frequent occurrence in females, particularly those of a robust habit, in 
whom the general vascular action is not diminished at the catamenial pe- 
riod. In consequence of the suppression of the menstrual flux, blood is 
discharged from various parts of the body, but particularly from those tis- 
sues which bear the closest analogy to that from which it is naturally de- 
rived. Hence we have one kind of bronchial hemorrhage arising from 
suppressed menstruation, and which is not usually either preceded or fol- 
lowed by cough or other pulmonary symptoms. Now, this discharge in 
i females is not dangerous; it goes away as it appeared, without any bad 
effects ; and the same may be said of hemorrhage from other parts result- 
ing from the absence of the catamenia. Such, you will recollect, was the 
case of a woman in the Chronic Ward, who had regular attacks of hsema- 
temesis at the periods in which the menses should naturally appear. No- 
thing is more common than to find this vicarious gastric hemorrhage in 
women, and yet how rarely do we see it preceded or followed by organic 
disease, or producing the least permanent lesion or even dyspepsia. Such 
hemorrhage may be generally said to be devoid of danger. As I men- 
tioned before, the translation is commonly from the mucous membrane of 
the uterus to a similar surface of the nose, lungs, stomach, or bowels. It 
seldom or never appears in a parenchymatous tissue ; and hence, in the 
lungs, rarely terminates in pulmonary apoplexy. There is this freedom 
from danger, however, only in those cases w T here no disease of the lungs, 
or tendency to pulmonary engorgement, previously existed. Thus, in the 
case of Eliza Herns, in whom, at the usual period of her menstrual eva- 
cuation, a vicarious epistaxis and haemoptysis occurred ; the source of 
hemorrhage was not confined to the bronchial tubes, but extended to the 
air-cells. The blood she expectorated was, at first, of a florid arterial 
colour, and was copious; it afterwards became dark-coloured, and less 
abundant, and its source, as w r as evident from the stethoscopic pheno- 
mena, was derived from the ultimate ramifications of the bronchial tubes 
and the air-cells. She had been subject to cough and expectoration of mucus 
for a year previously. 

With respect to the haemoptysis which attends pulmonary apoplexy, I 
shall only remark (as its symptoms are well known), that here you have the 
cough, dyspnoea, and other symptoms, following the hsemoptysis, and very 
frequently pneumonia, and even gangrene. I have stated before, that I con- 
sidered the two latter occurrences as resulting from the same cause which 
produced the pulmonary engorgement, and not as a consequence. I will 
pass over this subject at present, and proceed to give you a few general 
hints on the haemoptysis which accompanies tubercular consumption. 
You remember I remarked that it is a disputed point whether this spitting 
of blood be the cause or consequence of phthisis. When we come to 
consider this subject dispassionately, and leave out theories, we find, 
that on examining phthisical hemorrhage, we invariably perceive that the 
discharge is bronchial, and that it presents the usual characters of arterial 
blood. It is because the irritation is bronchial you have so many 
bronchial rales in phthisis ; and hence, if you find bronchitis at the top 
of both lungs, and none at the bottom of either, and this condition is per- 
manent, your suspicions are naturally awakened, and you are led to the 



HEMOPTYSIS. 239 

detection of tubercles.* I mention this fact, because it proves that one 
of the permanent characteristics of phthisis is the presence of more or less 
bronchitis. As the bronchial hemorrhage in phthisis is generally small, 
and finds a ready exit, it will not be easy for you to confound it with 
pulmonary apoplexy. The bronchial engorgement which occasions this 
hemorrhage often sets in at an early period of tubercular phthisis. When 
this happens, a copious haemoptysis may occur, and may be the first 
symptom which attracts attention to the state of the lungs. Hence 
haemoptysis is often erroneously considered as the cause of the consump- 
tion. I beg you to remark, that the bronchial tubes are also the principal 
source of the puriform expectoration which attends consumption, and that 
we are not to suppose that it comes exclusively from the cavities in the 
lung, for the quantity expectorated is by no means in proportion to the 
size of such cavities. Again, where the haemoptysis happens to be copious, 
it is thought to arise from ulceration, or erosion of the coats of the arteries 
which accompanies the tubercular destruction in the lung. An occur- 
rence like this is, I believe, extremely rare indeed. Such an injury is 
too serious, and would be followed by too rapid a fatality. Nay, you 
will even find, on dissection, that the bronchial tubes may be cut across 
by ulceration, and every other part of the tissue of the lung destroyed, 
while the coats of the artery remain comparatively uninjured, and its 
cavity obliterated, so that you can trace it passing like a string through 
the abscess. Neither have I observed that the haemoptysis which arises 
in phthisis is produced by ulceration on the mucous surface of the bronchial 
tubes, though I do not know whether this might not cause it, when the 
ulceration is high up near the trachea. 

I shall detain you no longer on the symptoms of phthisical hemorrhage 
(only remarking that it is generally in the advanced stage that it appears, 
frequently from induced bronchitis and hard cough, in which case it is 
generally scanty, or from abscess, although here, also, from the oblitera- 
tion of the arteries before mentioned, it must usually be slight;, as the 
symptoms of this, and the symptoms which accompany common severe 
bronchitis and pneumonia, are easily recognised, and have been sufficiently 
described in books. You will find that Cruveilhier instances diseases of 
the heart as a great cause of pulmonary hemorrhage. No doubt this is 
true in many cases; for if there be a serious impediment to the return of 
blood to the left auricle, it will induce pulmonary disease, and you can 
readily conceive how the valvular structure of the heart may bring on 
hemorrhage from the lungs. Now, gentlemen, while on this subject, I 
shall make one observation. Since Corvisart wrote his great book on 
Diseases of the Heart, and Laennec published his admirable discoveries, 
it has been the custom to call all hypertrophied hearts diseased. We 
must bear in mind that there are considerable enlargements of the heart in 
which we are not to look on the hypertrophy as a disease, but as a wise 
provision of nature for the prolongation of life. If a person be born with 
asthma, his heart will become enlarged, because, during each fit, a greater 
degree of stress and labour is thrown on the right ventricle, and conse- 
quently that portion of the heart becomes enlarged, and is hypertrophied 
in the course of time. The same takes place, to some extent, in hooping- 

* A bronchitic rale confined to the upper lobe of one or both lungs, resisting treatment, and 
accompanied or followed hy dulness, at first, slight, but gradually increasing, are as valuable 
physical signs of phthisis as any we possess. 



240 CLINICAL MEDICINE. 

cough, in bronchitis, or emphysema, which lasts for a considerable time. 
If an old man has constant cough and expectoration, and his lungs be- 
come emphysematous, hypertrophy takes place, and you will find his 
heart enlarged on examination after death. And are you to look on this 
as disease ? Not at all ; it is the means of prolonging his life. The 
practical bearing of the question is, that you should be very cautious in 
giving digitalis, and similar remedies, in such cases ; for if you thereby 
weaken the heart's action, the obstacle to the transmission of blood 
remaining the same, you do your patient a great injury and contravene 
the wise purposes of nature.* 

I shall say nothing at present of the other diseases which produce 
haemoptysis, for, when speaking at a future occasion on the subject, I 
shall be able to show you how it may proceed from engorgement of the 
liver, purpura, or scurvy ; at present let us proceed to the treatment. 
This, of course, must vary according to the source of the disease, for 
when it arises from the causes last mentioned, your treatment must be 
very much modified. Into a description of these passive hemorrhages I 
do not mean to enter, and shall only remark, that it is in such cases that 
opium should be given from the beginning, and in no other kind of 
haemoptysis. In common cases you may, towards the termination of the 
disease, particularly where bleeding and other antiphlogistic means have 
been premised, employ this remedy with advantage. We know that 
there are many cases of hemorrhage where opium, by its action on the 
nervous and vascular systems, proves a powerful styptic. Instances of 
this are seen in its power of arresting the flooding of parturition, and in 
another kind of hemorrhage to which I would point your attention, I mean, 
that bleeding from the gums which sometimes follows the use of mercury. 
I remember a case of this kind, in which the bleeding from the gums was 
excessive, and all remedies failed in arresting it. The medical gentleman 
who attended it had employed every means in vain, and came to me, at 
twelve o'clock at night, to see if I could tell him of any thing that might 
be of service. I said to him, u go home, and give two grains of opium 
immediately, and then half a grain every hour until the bleeding stops." 
He seemed a little incredulous, but, however, made trial of the remedy, 
as I directed, and before three grains of opium had been taken, the bleeding 
ceased. This cursory explanation will, I trust, prove useful to you in 
practice. In books you will find, that when you meet a case of hemor- 
rhage, you should give immediately acetate of lead, with opium and other 
styptics : but remember, that in nineteen cases out of twenty, you should 
not give opium with or without acetate of lead in the beginning. When 
venesection has been performed, and the bleeding continues, then you may 
give it, and give it in large doses. 

The remedies which I have spoken of are fitted for cases of slight he- 
morrhage, as that which occurs in phthisis; but when a person spits up a 
large quantity of blood from an affection of the bronchial tubes, or in con- 
sequence of pulmonary apoplexy, what will you do? Commence with 
bleeding your patient; and here a depressed state of the vascular system 
should not deter you from the adoption of an energetic practice. The per- 
son who gets an attack of this kind is frightened at the quantity of blood 
he spits; his face becomes pale, and his heart weakened in action, a for- 

* Doctor Corrigan has made some admirable observations upon the injurious effects of digi- 
talis in cases of permanent patency of the aortic valves. 



HAEMOPTYSIS. 241 

lunate occurrence, as it tends to diminish hemorrhagic excitement. In all 
cases where bleeding is required, after venesection, the next remedy in 
which I place confidence is ipecacuanha, to be given two grains every 
quarter of an hour, until there is some improvement, and then every half- 
hour or hour until the bleeding stops. Here I must remark that it is a 
mistake to suppose, that it is the nauseating effects of ipecacuanha, which 
alone produce a cessation of the bleeding; tartar emetic nauseates too, 
but it will not so effectually arrest the hemorrhage. Richter, the author 
of the German Elements of Surgery, was the first who pointed out this anti- 
hemorrhagic effect of ipecacuanha, and Dr. Sheridan of this city has shown 
that it may be given with success in haematemesis, although it may affect 
the stomach so far as to produce vomiting; it exerts the same influence 
over hemorrhage from the bowels, as I have frequently proved in this hos- 
pital; I prefer it to acetate of lead. I may be asked, do I reject the latter 
remedy? Certainly not; I give it, but only at the time I give opium; 
that is, towards the termination of the disease. Before I commence with 
the ipecacuanha, I generally prescribe a purgative injection and a power- 
ful saline purge, such as infusion of roses, sulphate of magnesia, and a 
little sulphuric acid. The purgative is intended in this case to act as a 
derivative from the lungs. We see every day the great sympathy which 
exists between the mucous membrane of the bowels and lungs, and we 
observe that in cases of phthisis, and the chronic cough of old men, where 
purgatives have been administered in the latter disease, or where diar- 
rhoea occurs in the former, that the discharge from the lungs is lessened. 
I had an old gentleman, some time ago, under my care for one of those 
chronic coughs; he got tired of me, and went to Leamington and con- 
sulted an eminent physician residing there. He was purged very actively, 
for a considerable time, and the expectoration and other pulmonary symp- 
toms began to decline, and finally were entirely removed. He wrote 
several letters to his friends in Dublin, detailing the improvement in his 
disease, and abusing Dr. Graves for being unable to do any thing for hira. 
He returned to Dublin, the shadow of his former self, cured of his cough, 
and died in about a month afterwards. His case strongly evidences the 
remarkable influence which discharges from the stomach and bowels pro- 
duce on discharges from the lungs and gives you a reason for the power- 
ful effects of purgative medicine in haemoptysis. With respect to digitalis, 
I must confess, that I never use it. There is another agent which you 
may employ in this disease, I mean the popular remedy of giving the pa- 
tient a tablespoonful of common salt, and making him swallow it without 
water. I have seen this stop hemorrhagic effusion in the case of a friend 
of mine, when I was in the university, who was attacked with spitting of 
blood late at night. At that time the good old custom of shutting the col- 
lege gates at twelve o'clock prevailed ; we were in great alarm, and could 
get neither physician nor medicine. We gave him salt, which he chewed 
and swallowed, and, after three or four spoonfuls, the bleeding stopped. 
We may, perhaps, account for this by considering that the action of the 
muriate of soda on the mucous membrane of the mouth and throat is pro- 
pagated to the air-passages and lungs ; you may, therefore, if you like, 
while you are tying up your patient's arm, in order to draw blood, give 
him a spoonful of salt, as it may produce a favourable effect. 

I have but little to add to what is generally known respecting the ter- 
mination and treatment of haemoptysis. It is strange to what extent a 
17 



242 CLINICAL MEDICINE. 

spitting of blood may proceed without being fatal. I attended a gentle- 
man from Belfast, along with the late Mr. King and Sir Henry Marsh, who 
expectorated blood most copiously every day for more than two months; 
and yet he finally recovered, and has continued to enjoy perfectly good 
health for five years since. Another gentleman had repeated attacks of 
most violent haemoptysis, for which he was frequently bled, and subjected 
to the usual treatment; he had likewise accompanying pleuro-pneumonia 
often recurring, and which produced permanent dulness of a great portion 
of the upper lobe of the right lung; his pulse was at all times quicker than 
natural, and naturally extremely tall and slender he had gradually become 
quite a skeleton, while the action of the heart was violent, and could be 
felt and heard over the whole chest; the upper portion of the right lung 
was not only dull but flattened, and in this portion respiration was very 
feeble, and during the attacks of haemoptysis mixed with crepitus. In this 
state he continued for two years, at times better, at times worse, rallying 
a little during the summer, but for the greater portion of his time confined 
to the house. At the end of that period I was again called to see him and 
was astonished at the alteration in his countenance, an alteration produced by 
the total cutting away of all his teeth, the consequence of the long-continued 
and enormous doses of mineral acids taken for the purpose of checking the 
haemoptysis which had so often returned. I felt quite surprised at find- 
ing him still alive, for I had believed that he had several months before 
died of consumption. Under the circumstances I advised a voyage to 
Australia, but on consulting Dr. Stokes and Sir Henry Marsh, I quite 
agreed with them in thinking his case too hopeless to allow us to permit 
such an experiment to be tried. Another year passed away, when we 
were again called to see him, and found matters apparently unaltered — no 
improvement, no aggravation either of the physical signs or constitutional 
symptoms; we now all agreed in thinking that as he had so unexpectedly 
survived, the voyage to Australia might be permitted. Accordingly he 
sailed in September, and perfectly recovered in New Holland ; at a sub- 
sequent period, he unluckily became ardently engaged in an attempt to 
convert some of the South Sea Islanders, by whom he was killed and de- 
voured. His was in truth a remarkable recovery, not only from repeated 
and terrible attacks of spitting of blood, but from many of the constitu- 
tional and physical symptoms of advanced phthisis. 

In the case of another gentleman attended by me and Dr. Stokes, suf- 
focation had nearly resulted in a manner not hitherto noticed by authors. 
This gentleman had been ill for many days, had been very often bled, 
and was much exhausted. I had visited him in the morning and had but 
just left him, when a fresh burst of blood took place. Contrary to my 
orders he was again bled, and when Dr. Stokes arrived, in about three- 
quarters of an hour afterwards, he found him collapsed, almost asphyxi- 
ated, and struggling for life. The right side of the chest expanding and 
contracting energetically, Me left almost fixed and motionless. Dr. Stokes 
immediately changed his position, and gave him a glass of wine, when 
he made one more effort and violently expectorated a coagulum consisting 
of fibrin, in some parts nearly colourless, forming a complete solid mould, 
answering to the left bronchus and its ramifications, down even to some of 
the minuter tubes. After this he rallied, and for the time was tranquil. 

In violent haemoptysis medical men are too apt to have recourse to 
venesection, over and over again, bleeding from the arm every time the 



PHTHISIS. 243 

spitting of blood returns.* Strongly as I advocate the necessity of using 
the lancet boldly when a patient is suddenly attacked with a copious dis- 
charge of blood from the lungs, yet I conceive that much injury is fre- 
quently inflicted by a too frequent repetition of the venesection : if after 
two or three free venesections, performed in the commencement of the 
disease, the pulse still retains its hemorrhagic character unsubdued by 
the loss of blood, and hemorrhage still exhibits a tendency to return 
(usually at a certain hour), the practitioner may rest assured that he will 
not be able to prevent that tendency by further venesections ; in cases, 
then, where bleeding from the arm is found neither to prevent nor dimi- 
nish pulmonary hemorrhage, we must not add to our patient's exhaustion 
by repeating it, and must steadily refuse when pressed to do so by the 
patient himself or his friends ; for the prejudice is general that (deeding 
from the arm is proper whenever a patient spits blood in quantity. It is 
true that the cases which are not benefited by bleeding are invariably of 
a most dangerous nature, and will terminate in most instances fatally, no 
matter whether we bleed or not ; still when we have once convinced our- 
selves, that bleeding has ceased to be evidently beneficial, either in arrest- 
ing or preventing the fits of haemoptysis, we must not hazard our patient's 
chance of recovery, however slight ; we must, on the contrary, husband 
his strength, and use the means generally recommended in so called 
passive hemorrhage. Acetate of lead in frequent doses, two grains every 
hour, with one-sixth of a grain of opium, large doses of sulphuric acid, 
with or without alum, small doses of spirit of turpentine (ten drops every 
quarter of an hour, given in cold water, while the spitting of blood con- 
tinues), and finally, in unmanageable cases, ipecacuanha, given in nau- 
seating doses, constantly repeated until full vomiting is produced over 
and over again. Such are the means which the physician will employ 
internally in these almost desperate cases ; when much debility ensues 
from repeated loss of blood, wine and opium may be given boldly. No 
topical bleeding has appeared to me so useful as a constant oozing from 
the hollow of the throat just above the sternum. The efficacy of leeches 
applied to this situation in bronchitis and other diseases attended with 
harassing cough, was long ago pointed out by Dr. Osborne ; and last 
winter I was induced, from frequently observing the admirable effects of 
this practice, to extend its application to cases of haemoptysis, and I am 
happy to say that it has proved a most excellent adjuvant in arresting 
the progress of this frightful complaint. When the cough is very teasing, 
and the quantity of blood expectorated very large, six leeches should be 
applied every sixth hour, until decided relief is obtained ; in less severe 
cases, a smaller number applied daily will be sufficient. When the dis- 



* [We agree most fully with Dr. Graves that venesection is often a 
doubtful and sometimes an improper remedy in haemoptysis. In fact, 
although we are fully aware that bloodletting is, in these cases, often a 
most necessary remedy, we are not in the habit of always ordering it in 
haemoptysis : we restrict it to those cases in which the patient has tolerable 
strength of constitution as well as a considerable increase of the action of 
the heart and arteries. In cases in which the patient's health has been 
deteriorated very much before the hemorrhage, we think that, although 
cupping is often useful, general bleeding should be entirely avoided. — 
W. W. G.] 



244 CLINICAL MEDICINE. 

ease is obstinate, a succession of large blisters to the chest maybe applied 
with advantage. 

With respect to the danger of phthisis supervening in cases of spitting 
of blood, it is remarkable that in recent cases of haemoptysis we cannot 
predict the event with any degree of certainty, for it often happens that 
the chest is every where clear on percussion, and free from morbid rales,* 
the pulse natural and cough trifling, in the very individuals that at some 
future period become subjects of phthisis. In other persons a violent 
attack of haemoptysis recurs over and over again during several weeks and 
then ceases, leaving them, however, much debilitated, but without cough, 
morbid stethoscopic phenomena, or fever. The medical attendant must 
in such cases be very guarded, for however flattering the appearances 
may be, convalescence will scarcely appear to have commenced, when 
the pulse will begin to rise, cough set in, and in a few days afterwards, 
manifest dulness and crepitus will be discovered under one of the clavi- 
cles ; in fact rapid consumption has commenced. In other patients, after 
an attack is apparently perfectly recovered from, and no % symptom of 
phthisis exhibits itself, until the constitution is worn out by repeated 
losses of blood ; then tuberculization commences suddenly and proceeds 
rapidly. 



LECTURE XXIII. 

Pathology of Phthisis — Formation of Tubercles. 

Gentlemen, — Phthisis is a disease of the highest importance, and calcu- 
lated to excite a very deep interest, whether we view it in relation to the 
insidious nature of its origin and progress, the selection of its victims, or 
the number and frequency of its attacks. From calculations founded on 
the tables of mortality and other data, it has been computed that sixty 
thousand persons die annually of consumption in Great Britain ; but as 
this computation has not been made with reference to the great increase of 
population within the last few years, it is probable that the average 
amount of deaths from tubercular phthisis may, without exaggeration, be 
eighty or ninety thousand in the year.f Phthisis is a disease which, more 

* I cannot agree with the author of the article Hemoptysis, in the " Library of Medicine" 
(Dr. George Burrotves), who, speaking of the difficulty sometimes experienced in distinguish- 
ing between hemorrhage from the lungs and that from the stomach, says, " This difficulty, 
however, is considerably lessened by the physical signs of disorganization of the lungs being 
readily detected by auscultation." Library of Medicine, vol. v. p. 27. I should have con- 
cluded that this opinion was derived from theory rather than experience, but the writer tells 
us further on, that he has paid considerable attention to this lesion. 

■j- From the following table it appears that the mortality has not increased to the extent 
mentioned in the text. It, however, only refers to the year 1837. This extract I have taken 
from a work which has lately appeared, viz., " Gilbkht On Consumption." 

"The total number of deaths registered in England and Wales, from July I to December 31, 
1837, both inclusive, amounted to 148,701. Of this number 27,754 were the result of con- 
sumption of the lungs, of whom 12,968 were males, and 14,786 were females. We, therefore, 
find, according to this authentic report, consumption caused twenty per cent, of the total num- 
ber of deaths, thus confirming Dr. Abercrombie's opinion, that one-fifth part of all the deaths 
are the consequence of this fearful malady. But if we take away 12,091 deaths from old age, 
and 4,845, which were violent, in all 17,536, we shall then find that consumption produced 
upwards of a fifth part of all those which resulted from the disease, thus bearing out the opinion 



PHTHISIS. 245 

than any other, demands the sympathy and excites the commiseration of 
the friends and acquaintances of the sufferers. Some diseases are borne 
in silence and concealment, because their phenomena are calculated to 
excite disgust; to others, the result of vicious courses, the stigma of dis- 
grace is attached ; unsightly ravages of the human frame, or the wreck of 
the mental faculties, inspire us with horror rather than with sympathy; 
but consumption, neither effacing the lines of personal beauty, nor damag- 
ing the intellectual functions, tends to exalt the moral habits, and develop 
the amiable qualities of the patient, and, from its melancholy character, 
gives to our feelings of commiseration a more than ordinary intensity. 
Most persons die of consumption in the bloom of youth, at a period when 
hopes are brightest, and the capacities for enjoying life are in full vigour 
and maturity ; most of its victims are remarkable for the early unfolding 
and brilliancy of their mental accomplishments ; and many a family has 
to regret, that, by tubercular phthisis, some of the fairest and best of its 
members have been hurried to an early grave. 

I am not, gentlemen, going to treat of the subject of consumption in 
detail ; I do not intend to enter into a description of its symptoms from 
their origin to their termination, to exhibit its various phases, or to enu- 
merate the stethoscopic phenomena observed during its progress. To do 
this would require a very long time, and many lectures ; my purpose is 
merely to give a general coup-rfczil of its pathology and treatment. The 
occurrence and development of tubercles in phthisis, constituting the most 
remarkable phenomena of the disease, have engrossed, almost exclusively, 
the attention of medical men, and consequently they have attached an 
undue degree of importance to them as the cause of phthisis. Here I beg 
leave to state, that I do not intend to enter into a description of the dif- 
ferent forms of tubercle, whether they occur as separate and distinct pro- 
ductions, or in the shape of tubercular infiltration ; this has been treated 
at large by Laennec, Andral, and various other writers ; but will only 
remark, that, with regard to tubercles, I am inclined to limit their influ- 
ence in producing consumption. I grant that tubercles, in either state, 
occurring in very great numbers, or very rapidly developed, will occasion 



of Dr. Young and Dr. Woolcombe, 


that one-fourth part of the deaths 


occurring from disease is 


the result of phthisis. The 


whole 


evidence is, therefore, singularly unanimous." 


" Extract from Table .1, 


contrasting 


the rate of mortality from 


consumption -with that 


from sixteen other diseases : 










Diseases. 






M ilea F males. 


Total. 


Cholera . 


. 


. 


246 214 


460 


Influenza 


. 


. 


220 364 


484 


Small-pox 


. 


. 


3,050 2,761 


5,811 


Measles . 


. 


. 


2.340 2,392 


4,732 


Ague 


. 


. 


39 37 


76 


Typhus Fever 


. 


. 


4,439 4,608 


9,047 


Hydrophobia 


. 


. 


13 3 


10 


Hernia 


. 


, 


150 102 


252 


Colic 


. 


. 


39 19 


58 


Diseases of the 1 


iiver 




1,018 891 


1.909 


Stone 


. 


. 


161 19 


ISO 


Rheumatism 


. 




221 216 


437 


U leers 


. 


. 


37 45 


82 


Fistula . 


, 


. 


39 12 


51 


Mortification 


* 


* 


305 276 


581 




26,8Sl 


CONSUMPTION 


. 


12,968 14,786 


27,754 



246 CLINICAL MEDICINE. 

very serious inconvenience and danger by diminishing the power and 
extent of the respiratory apparatus. If, instead of a pervious lung, you 
have one-half of this organ obstructed in its function by tubercles, the 
injurious effect on respiration is evident. Cases of this kind are of no un- 
common occurrence ; I have seen tubercles, to an extraordinary extent, 
make their appearance in the lung in the space of two or three weeks, and 
have known persons to die of the suffocation caused by this rapid develop- 
ment without the usual symptoms of phthisis.* We had, some time ago, 
an instance of this, in a young woman, in Sir P. Dun's hospital, who died, 
in fact, of what maybe termed tubercular asphyxia, arisingfrom the rapid 
and general formation of those morbid productions. She had scarcely any 
of the common symptoms by which consumption is characterized ; her death 
was the result not of the suppuration which attends phthisis, but of the 
suffocation which arose from imperfect respiration ; and this is a distinc- 
tion which I wish to draw strongly and broadly. It is, I believe, a gene- 
rally received opinion, that tubercles, by producing inflammation and 
suppuration, are the cause of phthisis. This I doubt, or even deny. 
I look on tubercular development and consumption as the conse- 
quences of that particular state of constitution, which occasions what is 
falsely termed tubercular inflammation, a state of constitution in which 
we have three distinct processes, attended by corresponding morbid 
changes, each different in itself, but depending on one common cause. 
Every form of consumption, which has hitherto come under our notice, is 
referable to one common origin, and this is that debilitated state of con- 
stitution which has been termed the scrofulous habit. One of the first 
tendencies of this habit is to the formation of tissues of an inferior degree 
of animalization, among which I class tubercles, whether occurring in the 
lungs, brain, or liver, whether they exist in a minute or granular form, or 
in large, soft, and yellow masses, or in the state of tubercular infiltra- 
tion. I look on them as one of the first of those morbid changes de- 
pending on a peculiar constitution of body, and most commonly found to 
accompany it. The weaker the constitution is, the greater tendency is 
there to generate tissues of a lower degree of vitality, and, on this prin- 
ciple, I think we can explain the occurrence of entozoa and hydatids. 
There are some cases in which you will never be able to prevent the 
generation of intestinal worms, until you direct your attention to the source 
of the evil, which lies in the weakness of the constitution, for, in such a state 
of the system, all animals are liable to the formation of parasitic produc- 
tions and tissues imperfectly animalized. I look on tubercles in this light, 
and not as the consequence of inflammation, nor do I consider that it has 
been proved, that tubercular development is the cause of phthisis. Many 
cases come under our observation, in which most of the symptoms of phthi- 
sis, and its attendant hectic, are manifest and striking, and, when the in- 
jury done to the lung is very great, still no tubercles can be detected. 
That the mere presence of tubercular matter does not occasion inflamma- 

* [Examples of this variety of tuberculous disease are not very uncom- 
mon amongst the blacks in the United States. This class of patients is 
more subject to various tuberculous disorders than whites, and they some- 
times die of acute tuberculous disorder, producing suffocation, without 
their having had any violent symptoms of an earlier disease of this na- 
ture.— W. W. G.] 



PHTHISIS. 247 

tion of any kind, may be inferred not only from the lungs, in which this 
fact is of every day occurrence, and a matter of every day observation, 
but also from finding them frequently in the spleen, liver, kidney, and 
muscles, where they must have existed for some time, and yet we cannot 
perceive any inflammation of the surrounding tissues. On the other hand, 
as we may have tubercles without any phthisical pneumonia or suppura- 
tion of the lung, so we may have also the latter without the former. Thus, 
in a man of middle age, who died lately in this hospital, the lungs were 
extensively solidified, black, and ulcerated, containing several sinuous 
cavities, filled with pus of a scrofulous character, but not a single distinct 
tubercle. There was not the slightest vestige of the chief kind of tuber- 
cle — the yellow one, nor could we find any of the small miliary transpa- 
rent kind ; the whole mass was solid, except where it was suppurating, 
evidently the result of phthisical pneumonia of a chronic nature. Occur- 
rences such as this have been frequently observed (and particularly in the 
phthisis of persons advanced in life) by Professor Alison and others ; but 
the preconceived opinion, that the solidification of the lung was the con- 
sequence of tubercular deposition, made them overlook its real nature. 
The most important thing for the student to impress on his mind, with 
regard to all cases of phthisis, is, that the pectoral symptoms, of whatso- 
ever nature they may be, are caused by scrofulous inflammation. If you 
trace the phenomena of external scrofulous abscesses, you will be struck 
with the close analogy they bear in their manner of appearance, their pro- 
gress, and terminations, to the ulcerations of the lungs in phthisis. The 
same slowness, the same insidious latency, the same gradual solidification 
and gradual softening, the similarity of the puriform fluid secreted in each, 
the analogous occurrence of burrowing ulcers and fistulous openings, the 
close approximation in the form of their parietes, and the difficulty in heal- 
ing remarked in both, make the resemblance between them extremely 
striking. Compare scrofulous inflammation of the hip or knee-joint with 
phthisical suppuration of the lungs: — have we not the same kind of hec- 
tic fever, the same flushings and sweats, the same state of urine, the same 
diarrhoea, the same state of appetite, and the same emaciation ? 

I mentioned before, that one of the first morbid changes we generally 
see arising from the scrofulous habit is the formation of tubercular matter. 
I have also alluded to another of those morbid changes, namely, the pro- 
duction of scrofulous pneumonia, in which we cannot detect the existence 
of a single tubercle. There is another process in which the scrofulous 
inflammation is seated in the bronchial mucous membrane. This latter 
form of phthisis is sometimes associated with phthisical pneumonia ; but 
it often exists without it. Although, in this disease, the inflammation is 
seated in the bronchial mucous membrane, it differs very much from com- 
mon bronchitis : its symptoms are different ; it does not run the. same 
course ; and it is unlike common bronchitis in its mode of termination 
and cure. Its fever presents all the material phenomena of phthisis — and 
emaciation, — frequently the same incurability ; the same means tend to 
its aggravation or benefit, and the same scrofulous pus is secreted. It 
has been urged, in opposition to the last analogy, that the matter expec- 
torated is not the same, because it is not found mixed with broken tuber- 
cles, as in cases of true phthisis ; but this is an accidental and not a real 
difference, and does not disprove their identity. We have instances of 
this species of inflammation affecting other mucous tissues ; as, for in- 



248 CLINICAL MEDICINE. 

stance, the scrofulous inflammations of the eyelids and conjunctiva, which 
we see sometimes going on for months, or even years, secreting a scrofu- 
lous pus, and requiring constitutional as well as local remedies for its 
cure. 

In like manner, we have frequent occasion to observe scrofulous sore 
throat, and scrofulous inflammation of the mucous membrane of the bow- 
els. The latter is very common in children, and manifests its tendency 
to hectic in what is termed the remittent fever of children. Its true 
scrofulous nature has been scarcely perceived by practitioners ; and yet 
its treatment and cure contain manifest proofs of its origin, independently 
of the subsequent disease of the mesenteric glands, observed in all fatal 
cases, and by all acknowledged to be scrofulous. It is scrofulous inflam- 
mation of the mucous membrane of the bowels which causes tabes mesen- 
terica, which occasions the swelling and puriform contents of the mesen- 
teric glands, in such cases. The disease of the glands has been falsely 
regarded as the cause of the chief symptoms : where it occurs, it aggra- 
vates and adds to them ; but it is itself occasioned by irritation of the 
lymphatics distributed to the surface of the diseased bowel, on the same 
principle that a bubo, or a chain of diseased glands in the groin, may be 
occasioned by inflammation on the surface of the penis or lower extremi- 
ties ; in the axilla, by sores on the hand, arm, or chest ; and in the neck, 
by cutaneous eruptions on the face or scalp, or by inflammation of the 
mucous membrane of the throat. In all such cases, if the original source 
of irritation at the extremities of the lymphatics leading to the gland be 
scrofulous, these glands will undergo precisely the same changes which 
we observe in the mesenteric glands in tabes mesenterica. 

These analogies being considered, you will, gentlemen, be more dis- 
posed to agree with me, in thinking that many of those cases of chronic 
bronchitis which induce a fatal hectic fever, and are accompanied by a 
copious purulent expectoration, are truly of a scrofulous nature, and con- 
sequently not so distinct from tubercular phthisis as is generally believed. 
This view of the subject leads to most important practical results ; for the 
practitioner who is aware of the true scrofulous nature of -the pneumonia 
which occurs in phthisis, whether with or without tubercles, and who 
does not regard either the inflammation of the lung, or of the bronchial 
tubes which accompany tubercles, as genuine simple inflammations caused 
by the presence and irritation of tubercles, acting as foreign bodies^ such 
a practitioner, I say, aw T are of the scrofulous nature of these affections, 
will pursue a line of practice very different from that too generally adopted, 
on the supposition that they are true inflammatory affections. 

You will remember, then, that w r e have three distinct forms of disease 
in the lungs, all arising from scrofula, namely, scrofulous pneumonia, 
scrofulous bronchitis, and tubercular development. We may, therefore, 
have tubercles without either the pneumonia or the bronchitis ; and we 
may have scrofulous pneumonia often ending in slow burrowing suppu- 
ration, and proving fatal without any tubercles being formed. In like 
manner, a person may die of scrofulous bronchitis without the occurrence 
of either tubercles or pneumonia. Of these three effects of scrofula, it 
may be remarked, that, owing to their cause and origin being the same, 
they are most frequently found in combination. The same diathesis 
which produces one may give rise to the others ; hence the frequency of 
their association ; hence it is that they generally occur together. 



PHTHISIS. 249 

I have stated, that I doubted, or even denied, that tubercles were the 
cause of suppuration in the lung; — you will ask me for proofs. In the 
first place, how many lungs will you find, on dissection, filled with tuber- 
cles, and yet there is no inflammation ? Out of one hundred cases of 
tuberculated lung, dissected by Laennec, you will remark that nearly 
eighty were found to be in the latent stage, and yet there was no vestige 
of inflammation. Now, how could this happen if tubercles acted like 
foreign bodies, as they are considered to do by many writers? If a grain 
of sand happens to get into the eye, it will excite inflammation. If tuber- 
cles were capable of producing inflammation, we should discover some 
traces of it in every lung where they are found to exist, and yet you will 
meet many cases in which you cannot detect the slightest trace of it down 
to the very edge of the tubercular mass. I instanced before the occur- 
rence of tubercles in the liver, spleen, kidney, and muscles, without any 
accompanying or surrounding inflammation. Indeed, I am adverse to 
allow that any animal product gives rise to inflammation. I do not speak 
here of unorganised calculi. I do not include those animal productions 
whieh are transferred to a part different from that in which they originated, 
as the matter of an hepatic abscess into the cavity of the peritoneum ; these 
are occurrences for which nature is not prepared. But no animal matter 
produces inflammation of the part in which it is deposited ; nor can I call 
to mind a single instance of such an effect. Extravasation of blood in 
the brain or lungs, or into the cellular tissue, does not give rise to in- 
flammation, neither does effusion of lymph into serous cavities. I look 
on tubercles in the same point of view, and consider them as productions 
incapable of developing the phenomena of inflammation. The inflamma- 
tion and suppuration of the lung, to which the name of phthisis is applied, 
is dependent on a scrofulous habit, and this leads us to inquire, wh;it is it 
that gives rise to the scrofulous diathesis? In many cases it is heredi- 
tary ; persons may be born with it ; and tubercles are frequently detected 
in the lungs of the foetus. We may, therefore, say, that under some cir- 
cumstances it is an hereditary disease. But it is not merely hereditary 
and existing in the foetus in utero,but may be developed at any period of 
life. It is of great use to study and investigate the causes which produce 
this disease in the lungs of persons who have lived for years without any 
manifestation of tubercles, as it furnishes us with a key to understand why- 
persons who have not originally either tubercles or scrofulous bronchitis 
may sometimes die of phthisis. It is too much the fashion to say that 
phthisis is an hereditary disease, and it is often useless and erroneous to 
lay too much stress on this opinion and on the result of an inquiry into 
the habits of the parents and relations of a patient who is supposed to 
labour under consumption. That the predisposition may be generated in 
utero,* I grant, is often the case, and, ca3teris paribus, a person with such 
a predisposition is much worse off; but I believe that it often happens 
that a man will get consumption from confiding too much in the purity 
of his blood, and I have known some cases of neglected cough terminate 
in debility and consumption, because the patient was not apprehensive of 
any danger, from the circumstance that none of his ancestors ever had the 
slightest taint of phthisis. There are several facts in proof of this. If a 
tiger from the wilds of Africa, who can boast of a line of ancestors as free 
from phthisis as any of us, be brought into this country, and debilitated 

* Billard has detected tubercles in the lungs of foetuses. 



250 CLINICAL MEDICINE. 

by confinement, impure air, and a climate to which he is unaccustomed, 
you will frequently find that he will die phthisical. Negroes, none of 
whose progenitors laboured under any form of phthisis, will get consump- 
tion in Great Britain. The same occurrence takes place with respect to 
monkeys and other animals, who are naturally inhabitants of a climate 
having a striking difference in temperature from that into which they are 
imported. You recollect the dromedary carried about for exhibition, 
which died in this city ; and was dissected at the College of Surgeons: 
this animal died of consumption. The white bear of the north of Europe, 
and the Esquimaux dogs, brought into this country, die of liver disease, 
though, I dare say, there is no instance of hepatitis among those who 
dwell in their native wilds. Here we have instances of disease not at all 
hereditary, acquired from the action of the same cause that favoured its 
development when hereditary, and tending to justify the opinion that 
phthisis may, under certain circumstances, occur in a habit in which the 
slightest predisposition to this disease does not exist. 

You will expect me, perhaps, to enter into a disquisition on the origin 
of tubercles ; this, for obvious reasons, I must refuse. Much labour has, 
I think, been fruitlessly expended in attempting to systematize this subject. 
The consideration of tubercles has been lately treated, with his usual 
ability, by my excellent friend, Dr. Rogers, in the Edinburgh Medical 
and Surgical Journal, and from his paper you will derive a great deal of 
useful information. I am persuaded that there is much of error and mis- 
conception in the manner in which many persons consider the nature of 
tubercular formation. I am convinced that many of the propositions laid 
down as tenable and well-grounded may be subjected to revision, or even 
doubted and denied. It is supposed, for instance, that the yellow solid 
tubercle, one of the best defined of those which are found in the lung, 
commences in one form and terminates in another ; that in the beginning 
it is small, solid, and transparent ; that as it grows larger it becomes more 
and more opaque, and afterwards, under the inflammatory process, becomes 
softened in the centre and suppurates, the suppuration extending towards 
the circumference. This I am inclined to doubt. When you find, on 
dissecting a scrofulous lung, tubercles with fluid matter in their centres, I 
can scarcely think you are authorized in saying they have been at any 
period of their existence completely solid. Twelve years ago, while 
perusing Laennec's descriptions of tubercular formation, I wrote on the 
margin of the copy I was reading, " Might not tubercles have been origi- 
nally fluid, and might not the change they undergo be from a soft into a 
consolidated mass ?" I have seen this passage of fluid scrofulous pus into 
solid tubercular matter beautifully exemplified in a case of psoas abscess ; 
the neighbouring lymphatics were loaded with this pus ; in the lymphatic 
glands to which it was next carried it was much thicker ; in those at a 
greater distance it was of the consistence of curd, and when its fluid par- 
ticles had been still more completely absorbed in more distant glands, it 
was found to be as solid as any yellow tubercle. May it not happen, 
that many of those yellow tubercles (and this is the opinion of Cruveilhier 
and others who have written on this subject since Laennec) at their com- 
mencement consist wholly of depositions of scrofulous pus in the tissue of 
the lungs. One of the supposed tendencies of the scrofulous diathesis is 
to modify nutrition in such a manner that, instead of the ordinary deposi- 
tions, a secretion of scrofulous pus takes place in circumscribed spots. It 



PHTHISIS. 251 

has been universally acknowledged, that we may have depots of pus 
without inflammation. Now, if those depots be excessively numerous 
and very minute, and if they continue for any length of time, they will 
be exposed to the action of the surrounding absorbents ; and as absorption 
will go on with greater activity at the circumference than at the centre, it 
is obvious that the solidification of the circumferential parts will precede 
that of the central, and they will present the appearance of tubercles 
softened in the centre. These facts I bring forward, not for the purpose 
of laying down any fixed theory concerning the growth and origin of 
tubercles ; not for the purpose of asserting that the generally received 
opinion is wrong ; but to show you that it has been too hastily adopted, 
to the exclusion of other explanations drawn from causes probably not 
less operative in giving rise to these morbid productions. With regard 
to the more minute forms of tubercular matter, as the granular and trans- 
parent tubercle, and the tubercular infiltration ; these I look upon as the 
effects of vitiated nutrition, a species of parasitic growths of a lower 
degree of organization, having their origin in an hereditary tendency, or 
in a debilitated state of constitution. These may, and frequently do occur 
along with the yellow purulent tubercles, and they may have purulent 
points deposited in their centres, or at the circumference ; but it may be 
doubted whether there is a true conversion or growth of one into the 
other, or, speaking more precisely, whether greyness, transparency, and 
minuteness of size in tubercles, necessarily precede opacity, yellowness, 
and considerable bulk. The nearest resemblance which exists between 
the two kinds is in the case of tubercular infiltration, the grey species 
being imitated in its mode of diffusion by the purulent infiltration of the 
yellow kind. 

The next subject for consideration is the examination of those causes 
which, acting on the constitution generally, or locally on the lung, give 
rise to the development of tubercles, scrofulous pneumonia, or scrofulous 
inflammation of the mucous membrane of the bronchial tubes. A great 
deal has been said concerning the badness of our climate, but it is neces- 
sary to know the comparative frequency of consumption in Great Britain 
in order to ascertain the influence its climate may exercise in producing 
this disease as compared with that of other climates. If you examine 
the records of the German, French, Italian, and other continental hos- 
pitals, you will find that the occurrence of phthisical cases is not less 
frequent in those institutions than in the infirmaries of Great Britain. I 
do not mean to say that in those countries so many persons die in propor- 
tion to the extent of the country as in Great Britain, or that so much of 
the population, taking town and country into consideration, are cut off* by 
phthisis as in Great Britain ; but of the town population, where numbers 
are equal in both, I believe the proportion of victims is nearly the same. 
The prevalence of phthisis is found statistically to depend on confinement, 
poverty, and vice ; and as these are most abundant in the condensed 
population of towns, we can perceive why consumption is so frequent in 
this kingdom. In consequence of the great manufacturing prosperity of 
England, no nation in Europe possesses so many considerable towns in 
proportion to its entire population or extent. Now, when we compare 
the frequency of consumption in persons residing in large towns, and in 
those who live in the country, the difference is very great indeed. This 
is not strange, nor unaccountable. Compare the peasants of any, even 



252 CLINICAL MEDICINE. 

those shires which are believed to have the worst climates, in England, 
or even Scotland, and you will be at once struck with the contrast between 
them and the sallow artizans of large towns, who are crowded together in 
manufactories where ventilation is imperfect ; where they are obliged to 
work in confined postures for many hours together, and the time devoted 
to amusement and healthful exercise is scanty and insufficient. It is 
scarcely credible, the length of time even very young persons are made 
to work. From investigations made by a parliamentary committee during 
the last year,* it appears that in some towns of England and Scotland 
every principle of humanity has been violated. Children of six years of 
age have been crowded together by hundreds, in badly ventilated apart- 
ments, and obliged to work for seventeen hours in the day ; and when 
these ill-fed and sickly creatures dropped asleep over their work, as they 
frequently did, from fatigue, exhaustion, and the curtailment of their 
natural rest, they were kept awake by strapping them with a leather 
thong over the back. And can we be surprised that this should make 
them, as they are, spiritless, pale, and emaciated ; and that they should 
sink rapidly into that state which tends to scrofulous development? Is it 
wonderful that in such creatures every disease of debility should manifest 
itself in tenfold vigour ; that we should have phthisis in the lungs, and 
tabes mesenterica in the abdomen, and chronic hydrocephalus in the brain ? 
What applies to those of tender age is applicable also to the adult: the 
same mode of life is equally destructive to both; nay, it even fixes its 
stamp on the race, and you can recognise at once the pale unhealthy hue, 
and the stunted growth, of those whose progenitors have been manufac- 
turers and artizans for generations. If the population of these countries 
lived in one great London, or one great Manchester, deprived of the be- 
nefit of pure air and wholesome exercise, I verily believe that they would 
all become scrofulous — that nine-tenths of them would get phthisis, and 
that scrofula, in its various shapes, would sweep them off in the course of 
a few centuries. Cholera or plague would be preferable to this. But no 
manufacturing town supplies exclusively its own population; it generally 
draws from the country to support the losses it sustains by the natural 
decay and exclusive mortality of its members. It is the habits and cir- 
cumstances of those persons who live in towns that produce the fre- 
quency of phthisis in Great Britain, for its climate is not more unhealthy 
than others. I mention this particularly, because a very prejudicial pre- 
ventive method has been founded on the supposed inflammatory origin of 
phthisis. Confinement, heat regulated by the thermometer, flannel, low 
diet, and venesection, have been recommended as the best mode of 
managing phthisis. Now, if we complete the above catalogue by the 
liability to cold to which it brings on, the mental anxiety, and other cir- 
cumstances, we have what in due time would make many persons phthi- 
sical. It is of great importance to know how to make a man phthisical, 
as, by pursuing an opposite line of conduct, we will be able to prevent it. 
I have stated, that I considered tubercles not as the cause of phthisis, 
but as the result of a certain diathesis, to which the name of scrofulous 
habit had been given; I should, however, be conveying an erroneous idea 
of the peculiarities of the disease, if I were to omit mentioning that what- 
ever produces a tendency to the lungs gives rise to phthisical develop- 
ment. You will find in the works of Laennec, that he states that bron- 

* This lecture was delivered in 1832. 



PHTHISIS. 253 

chitis never hastens the development of tubercles. I must, in the most 
positive manner, deny the truth of this statement. It is a very dangerous 
thing for a person of a scrofulous habit to get an attack of cold, producing 
catarrh, or inflammation of the lungs, as it has a direct tendency to bring 
on tubercular development and suppuration. If persons be weakly, un- 
healthy, and of a scrofulous constitution, and get cold and inflammation 
of the lungs, they are more liable to have consumptive suppuration of the 
congested than of any portion of the lung ; for the same reason that a sim- 
ple injury, producing inflammation of the hip or knee-joint in a scrofulous 
habit, may degenerate into true scrofulous ulceration of these parts. Hence 
common bronchitis in a scrofulous habit may become true scrofulous bron- 
chitis, and common pneumonia may end in the scrofulous consolidation 
and burrowing ulceration of the lung peculiar to phthisis. 

I am afraid, gentlemen, that you will think me tedious and guilty of re- 
petition on this subject; but its importance is paramount, and I wish to 
impress on you that every form of phthisis is connected with scrofulous 
inflammation of the lung. Compare scrofulous and long-continued inflam- 
mation of the knee or hip-joint and their attending symptoms with the 
symptoms of phthisis. Have we not the same fever, the same sweats, the 
same diarrhoea, the same emaciation, the same state of urine and pulse? 
Are not all the symptoms which attend these diseases, I mean the general 
and constitutional symptoms, identical? Let me observe that there is not 
one of those cases in which you will not be able to trace the existence of 
scrofula, and I trust that you will assent to this proposition, that the in- 
flammation of the lungs in phthisis is scrofulous. You may be inclined 
to doubt that there is such a thing as scrofulous bronchitis, but let me re- 
mind you, that there are cases of persons in the decline of life who have 
long-continued cough, purulent expectoration, emaciation, sweats, hectic 
fever, and diarrhoea; and when you dissect one of those persons, you find 
the mucous membrane of the bronchial tubes red and hypertrophied, and 
a great quantity of purulent fluid in the lungs, but not the slightest trace 
of tubercle. You may say, I have made here a good diagnosis, this per- 
son has died of chronic catarrh ; but this is improper ; many of those cases 
are scrofulous inflammation of the bronchial mucous membrane. You will 
generally observe that those cases are much more difficult of cure than 
mere bronchitis; that the same treatment, the same regimen, the same at- 
tention to change of air, and tonic and strengthening diet, will not do. 
No one dies from an attack of common bronchitis except the very aged, 
or persons in whom it is very general and very acute ; and here its rapid 
termination sufficiently distinguishes it from the form I have described ; but 
we have repeated instances of bronchitis lasting for months without de- 
stroying the patient, and capable of being removed by the ordinary means, 
except when it occurs in a scrofulous diathesis. It is obvious that phthi- 
sis may prove fatal by the rapid and extensive development of tubercles 
without any of the peculiar phenomena of pneumonia or bronchitis; yet it 
most commonly happens that owing to their being produced by the same 
cause, we have the three different forms of scrofulous inflammation in the 
same phthisical patient, although it is by no means rare to meet with them 
in a separate and distinct state. 

I have mentioned on a former occasion that I did not consider inflam- 
mation as the cause of tubercular development; nevertheless, I must not 
omit stating, that it greatly increases the tendency to it by bringing more 



254 CLINICAL MEDICINE. 

(generally unhealthy) blood to the lung, and thus encouraging the forma- 
tion of morbid deposits; and this leads us to the consideration of another 
question, why are tubercles so common and so copious in the lung more 
than in any other tissue? I believe there has not been as yet any satis- 
factory solution of this phenomenon; but it may tend to throw some light 
on this obscure subject, if we call to mind one of the most striking pecu- 
liarities of the lung, namely, that it is the only organ through which the 
entire mass of the blood circulates. Through other organs, a portion only 
of the blood is transmitted ; but the whole current of the circulation passes 
through the lungs. It is in the lungs also that the change which the blood 
undergoes takes place exclusively, and its particles experience that muta- 
tion which renders them subservient to the purposes of life. Whatever 
has been added or subtracted from the blood by the processes of sanguifi- 
cation or secretion is corrected by the operation which it undergoes in the 
lungs, and hence they stand in relation to the blood differently from other 
parts. They receive, transmit, and produce changes in the blood differ- 
ing from those it experiences in any other organ, and this^ may perhaps 
account in some way for the frequency of tubercles in the lungs. Tuber- 
cles are a disease of nutrition, a process which depends intimately on the 
blood ; and it may not seem strange that they should be most frequent and 
numerous in an organ which has a more intimate connection with the san- 
guineous circulation than any other. I have stated that in persons of scro- 
fulous habit, whatever produces congestion in the lung is liable to bring 
on phthisis, and hence it is that tubercles are found to succeed the differ- 
ent forms of chest disease in which congestion of the lung is a general fea- 
ture. It is not that more blood passes through the uninrlamed portion, or 
that it receives more than the sound part. On the contrary, perhaps one 
hundred times as much blood is transmitted through the healthy part, but 
the mode in which it passes is very different. It passes rapidly and freely 
through the uninrlamed portion of the lung, and is aerated on its passage; 
but in the inflamed part the blood is retarded in its progress, and compa- 
ratively speaking, stagnates: it is, as it were, out of the general current 
of the circulation, hors de la route; it becomes diminished, both in its ve- 
locity and quantity, because the unsound and disorganised portion of the 
lung is unable to effect those vital changes which depend on the perfect 
state of its functions. Hence, you perceive, that whatever increases the 
stagnation of blood or the engorgement of the lung brings on a state of that 
fluid in w T hich there is both detention and imperfect aeration, circumstances 
which are apt to produce, not the nutrition of the organ in which they 
occur, but the formation of morbid depositions, and this appears to be the 
reason why inflammation and engorgement occasion tubercular develop- 
ment. 

With regard to the time of life at w r hich phthisis is found to occur most 
frequently, Lombard, Alison, and Andral have corrected some important 
errors in the opinions previously existing on this subject. From their 
investigations, it appears that, from one to two years of age, tubercular 
consumption is very rare, that its frequency increases from four to five, 
that it then remains nearly stationary until puberty, when the tendency to 
tubercular development is suddenly revived. As old age comes on, this 
tendency diminishes, and tubercular consumption is of comparatively rare 
occurrence, but scrofulous inflammation of the lungs is then also not un- 
frequently noticed. In the consumption of young persons we most com- 



PHTHISIS. 255 

monly meet with tubercles on examination after death, but in old people 
tubercles are seldom found, and in dissections of those who die of phthisis 
at an advanced age, we generally observe ulceration, abscesses, fistulous 
communications, and consolidation of various parts, with quantities of 
scrofulous pus. Such was the case of the man who died here some time 
since, in whom the ravages committed by scrofulous ulceration were very 
extensive, but there was not a vestige of tubercle. This form of phthisis 
is also frequently noticed in persons of middle age who have lived intem- 
perately and weakened the system by dissolute causes. 

I wish to make some additional observations now on the phthisical 
habit, and the circumstances which increase the liability to consumption. 
There are many circumstances which tend to the development of phthisis 
through the medium of their influence on the constitution. In the first 
place, persons who have had debilitating and protracted fevers, particu- 
larly if there be any affection of the lungs, are very apt to fall into what 
has been termed galloping consumption after the subsidence of the fever. 
In the next place, you will often find symptoms of phthisis coming on in 
females of a weakly habit when they attempt to nurse. In many females, 
of delicate constitution, you are aware that the progress of consumption 
is checked by utero-gestation. As soon as the female becomes pregnant, 
the phthisical symptoms disappear ; but when she begins to nurse, they re- 
turn again in an aggravated form. When such persons begin to nurse you 
should watch the effect of this new drain on the constitution ; you should 
observe whether their strength diminishes ; and if you find them becom- 
ing pale, thin, and emaciated, you should make them give up nursing, 
particularly if there be a tendency to phthisis in their habits. Among the 
male sex, nothing more frequently produces phthisis than syphilis and the 
abuse of mercury. There is no receipt more infallible than this for pro- 
ducing consumption. Take a young man, even with an excellent con- 
stitution, who is labouring under syphilis, shut him up in a close room, 
dose him with mercury, put him on low diet, and prevent him from the 
enjoyment of fresh air, wholesome exercise, and enlivening conversation, 
and you will certainly make him phthisical, if this process be often re- 
peated. Other diseases, such as diabetes, cancer, diarrhoea, insanity, 
hypochondriasis, and hysteria, have also a tendency to bring on consump- 
tion. If you consult Laennec, you will find enumerated among its causes, 
mental anxiety, depression of spirits, and such diseases will frequently lay 
the foundation for phthisis. In speaking of some of the religious orders 
in France, particularly those to which females are attached, he says that 
it is to be lamented that they were so unreasonable in their mode of life. ; 
for the confinement, want of recreation and exercise, which attended their 
mode of living concurring with their rigid abstinence, produced consump- 
tion in a few years. You should bear those circumstances in mind, and 
remember that there are various causes which tend to the development of 
phthisis, among which you are not to forget those which operate on the 
system through the medium of the mind. Analogous to this is that ill- 
judged pursuit of knowledge, which we often with regret observe to cut 
short the earthly career of the industrious medical student. No matter 
how vigorous a young gentleman may be, he will make himself consump- 
tive in two or three years if he chooses. Let him remain constantly in the 
dissecting room, or in attendance on lectures, keep his mind intently and 
anxiously engaged, let him snatch a hurried meal, for which he has no 



256 CLINICAL MEDICINE. 

appetite, take no exercise, and abridge his natural portion of sleep, he 
will quickly bring on that state of constitution in which the consumptive 
tendency so commonly appears. By pursuing this course of life, many 
young men fall victims to phthisis at an early age, and give melancholy 
proofs of the power of a combination of mental and physical causes in 
producing this disease. 

You will ask me what is to be done, in order to avert this phthisical 
tendency ? It was formerly thought, that consumption arose from inflam- 
mation of the lung, and, on this erroneous reasoning, was founded its 
preventive treatment; the patient was confined to his room, and kept in 
an equable temperature, wrapped up in flannel. I well remember this 
mode. If a family lost one of its members by consumption, these were 
the means employed to avert its occurrence in those who remained. 
This absurd plan was followed with rigorous exactness, and the constitu- 
tions of the survivors were so debilitated thereby, that they became simi- 
larly affected, and in time the whole were swept away. All these pre- 
cautionary measures generally tend to the same purpose,^ to make the 
constitution delicate, and consequently more liable to the inroads of 
phthisis. A rational physician will endeavour to prevent its occurrence, 
not by confining his patient, and wrapping him in flannel, but by harden- 
ing him against cold. Any one, who wraps himself up and confines him- 
self within doors, takes cold in ten-fold proportion to the person who dis- 
penses with superfluous covering, washes his chest with cold water, and 
rises early in the morning. Habits such as these, with a good nutritious, 
but not stimulating diet, and exercise, are the best preventives of phthisis. 
Make your patient lay aside slops and tea ; let him take wholesome fresh 
meat, bread, and good beer ; let him rise early and breakfast early, let 
him dine also early ; when the weather permits, let him remain in the open 
air for four or five hours, taking exercise on a jaunting-car, or on the top 
of a coach. The good diet will invigorate the system, and, so far from 
producing inflammation, will do exactly the contrary. No superfluous 
muffling should be used, nor would I recommend young gentlemen who 
wish to avoid cold, to come to hospital in the morning with a boa round 
their necks. Exercise should also be taken on an open vehicle, close 
carriages avoided, and the patient should commence cautiously the plan 
recommended by Dr. Stewart, of Glasgow, of washing the chest with 
vinegar and water, beginning with it warm, and reducing the tempera- 
ture gradually until it can be used completely cold. You will have great 
success in preventing phthisis by following this plan. In all cases, also, 
where phthisis is hereditary, I would strongly recommend the insertion of 
issues or setons* in the chest, before or after puberty, and I am of opinion 

* [For some years I have been very little inclined to advise the em- 
ployment of issues or setons in phthisis. In some cases these remedies 
are of great value, but in many instances I believe they do a positive harm 
to the patient, not only by the direct irritation they occasion, but also from 
the more important indirect mischief they produce by diminishing the power 
of the patient to take abundant exercise in the open air, which is all-im- 
portant in the management of phthisis. I now use these remedies very 
seldom in the treatment of phthisis. Blisters, or the irritation caused by 
the application of croton oil or tartar emetic to the chest, seem to me to 
be generally preferable remedies. — W. YV. G.] 



PHTHISIS. 257 

that if you happen to have an application made to you for advice before 
the disease commences, you will certainly avert its occurrence by this 
practice. You should, however, employ this mode of treatment with due 
consideration ; issues and setons are very unpleasant things, and you 
should not make your mode of prevention more powerful than necessary. 
The only cases in which you are authorized to have recourse to them, as 
preventives, are those in which there is a family predisposition to phthisis. 
I look on issues and setons as one of the most important means in the 
prevention, if not in the treatment of phthisis. Their utility in diseases 
of the hip-joint and spine has been long acknowledged. It is the knowl- 
edge of this fact which induces me to recommend them in phthisical 
cases ; I consider their value very great ; and when I employ them, I 
generally recommend a nutritious diet, which is of advantage where there 
is an outlet for matter from the system. I never treat a case of decidedly 
incipient phthisis without inserting, at least, two setons under the collar- 
bones. The following observation, made by an intelligent medical friend, 
is deserving of attention. " I had inserted a seton over the left mamma, 
where bronchial rules, diminished respiration, and commencing crepitus, 
indicated advancing tubercular inflammation. These stethoscopic phe- 
nomena were much increased every time he caught cold in his chest, and 
he felt sensibly, by the wheezing and uneasiness in that part of his chest, 
that whenever he caught cold, the lung there was most engaged. The 
effects of the setons were such, that, in the course of three months, having 
contracted a severe cold, that part of the lung was comparatively free 
from the bronchitis." For the accuracy of this fact I can vouch. 

Concerning the climate to which we may find it necessary to recom- 
mend a patient to remove, either for the prevention or alleviation of phthi- 
sis, I shall now offer a few remarks. When you enjoin a change of cli- 
mate, and make persons leave the country in which they have lived from 
infancy, you should not send them to the same, or nearly the same, cli- 
mate ; the change should be to a completely opposite one. Italy, the 
south of France, or Madeira, are not sufficiently different. It is absurd, 
in my mind, to send a patient from the British islands to any part of the 
continent of Europe. Towns on the sea-coast of any part of it will not 
do ; I would prefer the East or West Indies, South Carolina, or Florida, 
the northern states of South America, or Egypt. Many improvements in 
the social condition of the last named country tend to render it a desirable 
place of residence ; and if the present enlightened Pacha continue to pro- 
mote the advantages which it has gained within the last few years, it will 
become as agreeable a place of residence as any person can desire. 
Moreover, Clot Bey has confirmed the statement of Savary, that in Egypt 
pulmonary diseases are almost entirely unknown. 

I come now to speak of the treatment of phthisis itself, and shall make 
but very few observations on this subject, for you will find the history of 
its general symptoms, stethoscopic phenomena, and method of treatment, 
amply detailed in books. W T ith regard to the cough, I may remark, that 
in the first stages of this disease it presents great varieties, being gene- 
rally, in the commencement, baffling, and consequently scarcely noticed 
either by the patient or his friends. In some it precedes, in others it 
follows, a notable degree of emaciation and debility ; and it is worthy of 
notice, that it is not unusual for the patient to complain of increased per- 
spirations at night, long before the pulse is at all accelerated, long before 
18 



258 CLINICAL MEDICINE. 

the symptoms of hectic fever have commenced. These night-sweats are, 
at this period of the disease, the result of that debility, to whose presence 
the subsequent development of phthisis itself is mainly owing. At a sub- 
sequent period, the sweats are increased by the hectic fever, whose pa- 
roxysms end in cutaneous perspiration. Still, however, the original de- 
bility aids in their production, a fact which, in the treatment of this disease, 
should be borne in mind, for it may be considered as always proper to 
check this tendency to perspiration in phthisis, particularly in its com- 
mencement, for it uselessly debilitates the patient, and renders him much 
more liable to cold. Hence, when a patient applies to me, complaining 
of some debility, and a slight degree of emaciation, an J fading of healthy 
appearance ; if he has had a slight, but by no means troublesome, cough 
for several weeks — a cough, indeed, which he scarcely observes himself, 
but which excites the fear of some anxious friend ; if, in addition to this, 
he sweats rather more than usual at night, then, although his pulse be 
quite tranquil, although there exists no trace of hectic fever, yet I imme- 
diately direct my treatment with a view of checking this tendency to 
night perspiration, as well as the other more prominent symptoms. To 
such persons I generally recommend some such draught as the following, 
to be taken three times a-day. 

R. Infusi cascarillse, gvij. 
iSulphatis quininse, gr. ss. 
Acid. Sulphurici dilut., gt. xv. 
Tincturae hyosciami, gss. 

These draughts, together with constant gestation in the open air for an 
hour and a half at a time, and several times a-day, with nutritious diet — ■ 
meat, bread, and beer, for breakfast, meat for luncheon, and a dinner, 
with one or two glasses of wine, and no tea in the evening, will soon 
check the perspirations, diminish the cough, and rapidly recall the pa- 
tient's strength and vigour. .Many German physicians have an aphorism, 
that sulphuric acid tends to increase pectoral affections. So it occasion- 
ally does ; but given, combined with hyosciamus, as above recommended, 
its beneficial action, in giving strength and tone to the constitution, soon 
enables the patient to shake off the cough. 

In the month of January last, I recommended this prescription and 
general treatment to the eldest son of a gentleman of rank. His state was 
exactly what I have above described, and several of his mother's family 
had died of consumption. In a few days, his mother-in-law called at my 
house, and, in the course of our conversation, it became clear that she 
entertained very strong prejudices against the treatment I had recom- 
mended. Such persons, gentlemen, are all well acquainted with sulphate 
of quinine ; ladies of fashion use it constantly to wind themselves up, 
when reduced to a little below par, by dissipation and late hours. What 
use could sulphate of quinine be to a cough ? Might he not catch fresh 
cold from driving out at this season ? Would not the meat diet tend to 
increase the pectoral affection ? Luckily for me, this lady lived at the 
time in a country house, the nearest place to which had, many years ago, 
been the residence of one of our richest merchants, a gentleman with a 
very numerous family, eleven of whom have since died of consumption. 
My answer to the lady was, therefore, obvious. I replied, to prevent 
consumption, or remove its first stages in that family, the most eminent 



PHTHISIS. 259 

physicians recommended a certain regimen and mode of treatment. They 
were anxiously confined within doors during winter, kept wrapt up in 
flannel in rooms maintained at a Madeira temperature, were not allowed 
animal food, and were bled to the amount of a few ounces at each acces- 
sion of fresh cold. You, yourself, know the result, madam : — they all fell 
victims to the complaint, and appeared to droop more rapidly in conse- 
quence of the treatment. I am pursuing, in the case of your son-in-law, 
an opposite course. She was satisfied, and the young man is now strong 
and healthy. In spring, 1832, I was consulted by a young barrister who 
was affected in nearly the same manner, but, in addition, had a hoarse- 
ness and much more violent cough, and was more emaciated. The same 
regimen ; the same medicines ; the solution of nitrate of silver applied to 
the tonsils and pharynx ; early hours ; removal to Bray, and driving 
through the open air twenty miles a-day, restored him to health. Being 
now aware of what injures him, he avoids every thing debilitating, never 
neglects exercise, and is now strong and able to pursue his professional 
avocations. Again let me repeat it, that if the disease be at all more ad- 
vanced than it was in these two cases, I immediately insert one or two 
setons over the most suspected part of the lungs. When the preparations 
of hyosciamus are well made and good, they are extremely useful, and, 
like digitalis, exert a retarding influence over the pulse when it is acce- 
lerated. 

When the pectoral symptoms are accompanied with evident fever and 
a quick pulse, I generally combine these two substances as in the follow- 
ing formula: 

R. Sulphatis quininre, gr. jss. 
Aci«l. sulphur, dilut. gj. 
Tincturae digitalis, gt. xx. 

hyosciami, 3J. 

Syrupi papav. albi, ^ss. 
Aquae fontanre, £iv. 
Fiat mistura, sumat cochl. j. amplum 2a. q.q. hora. 

As the disease advances, the difficulty of producing a favourable result 
increases in tenfold proportion ; and I do not think that I can offer any 
remarks upon its treatment or mitigation which you will not find detailed 
in the various treatises on this disease lately published. 

But, before I conclude, let me impress on you strongly the necessity of 
never abandoning cases of consumption as hopeless ; for 1 have known 
several apparently desperate cases cured, even when puriform matter had 
been expectorated, and cavities existed. In a preceding part of this lec- 
ture, I have stated that the premonitory cough of phthisis is generally 
trifling, and scarcely attracts the notice of the patient himself. This, 
however, is not always the case. Thus, the lamented Mr. Wolf, the 
author of the celebrated stanzas on the death of General Moore, had, for 
a year before emaciation and hectic commenced, a frequently-repeated, 
single cough, exceedingly loud, ringing a metallic — in fact, a tussisfirma : 
during this time his pulse was natural and his breathing tranquil. Nothing 
that the ingenuity of Dr. Cheyne could suggest was of the least service in 
allaying the violence of the cough : nothing softened it, until it passed 
into the usual cough of true consumption, and then we too truly antici- 
pated the loss Mr. Wolf's friends must prepare themselves to sustain. 

I have seen a tussisfinna, such as I have described, perfectly dry, un- 



260 CLINICAL MEDICINE. 

interrupted except daring sleep, and very harassing in young ladies shortly 
after the age of puberty, and in whom the menstrual evacuation was scanty 
and irregular. In such cases the stethoscope discovers no disease ; a full 
breath can be drawn ; and during sleep the respiration is not hurried. 
The tonic treatment consisting of large doses of carbonate of iron ; the 
occasional exhibition of the spirit of turpentine, repeated for several days 
so as to act on the bowels, and given in as large quantities as can be 
borne, — these medicines, I say, combined with active exercise, the occa- 
sional use of aloetic purgatives, and finally the exhibition of tincture of 
cantharides, compound tincture of bark, and camphorated tincture of 
opium, according to the formula I have given for the cure of hooping- 
cough in the Dublin Medical Journal, will succeed in removing the dis- 
ease. This mode of treating this species of cough is quite new, and sug- 
gested itself to me after all the usual remedies had failed. Dr. Nalty, of 
Clare-street, witnessed a case of this nature which yielded to these reme- 
dies, and which had baffled the most judicious exertions of several emi- 
nent practitioners in the country. 



SYPHILIS. 
LECTURE XXIV. 

Dr. Roe's Report on Syphilis — Treatment of Gonorrhoea — Mr. Hoskins on Purulent 

Ophthalmia. 

I shall now, gentlemen, proceed to lay before you some observations on 
syphilis. Bell, Hunter, Matthias, Pearson, Carmichael, Rose, Hennen, 
Colles, Wallace, and Ricord, have so diligently investigated the history, 
symptoms, and special pathology of venereal affections, that I consider it 
unnecessary to touch upon these matters at present, and consequently I 
mean to confine my remarks to a few controverted subjects connected 
with the general pathology and therapeutics of syphilitic diseases. 

I hold in my hand a report, by my friend Dr. Roe, containing a return 
of the venereal patients treated in the 38th Regimental Hospital, from the 
11th of June, 1836, to the 15th of November, 1837 ; giving in separate 
columns, the names, ages, forms of disease, periods of admission and dis- 
charge, duration of the treatment, and remarks. The compiler, Dr. Roe, 
was a fellow student of mine, educated in Dublin, and always noted for 
his intelligence, accomplishments, and steadfast zeal for his profession. 
Under Dr. Colles, and the surgeons of the Lock Hospital, he had ample 
opportunities of witnessing the effects of the mercurial treatment of syphilis. 
He has treated the disease in the East Indies, the Ionian Isles, and at 
home, and from his habits of observation, sagacity, and attention, any 
statement coming from him must be very valuable. During the period 
from the 11th June, 1836, to the 15th December, 1837, the number of 
patients treated in the hospital of the 38th Regiment was 231. Of these, 
bO were affected with gonorrhoea, 87 with chancre, 36 with bubo, 23 with 
hernia humoralis, and 4 with chancre and bubo. 90 were under 20 years 
of age ; 95 from 20 to 25 ; 23 from 25 to 30 ; and 17 from 30 to 40, and 



SYPHILIS. 261 

upwards. Several caught the infection more than once during the space 
of time mentioned. Thus, Henry Carter was admitted for gonorrhoea on 
the 11th of June, 1836 ; again for gonorrhoea, on the 25th of February, 
1837 ; and again for the same on the 4th of May, 1837. John Adams, 
twice for gonorrhoea ; Arthur Nesbitt, twice for chancre ; John Williams, 
twice for chancre ; William Bexham, twice for chancre ; John Jess, once 
for gonorrhoea, and a second time for bubo. With respect to the duration 
of these cases, treated wholly without mercury, Dr. Roe gives the follow- 
ing summary: — The cases of gonorrhoea were on an average 15 3-7th 
days under treatment; chancre, 21 4-1 1th days; bubo 27 J ; swelled 
testicle, or hernia humoralis, 11 3-5th ; severe cases of chancre with bubo, 
18£ days. The following was the general plan of treatment pursued by 
Dr. Roe, and first with regard to gonorrhoea. The men on admission 
having been washed with warm water and soap, were ordered to take an 
aperient mixture, composed of sulphate of magnesia and tartar emetic, 
every third hour, until the bowels were freely opened. A small piece of 
lint w r as applied to the orifice of the urethra, and a short roller soaked in 
cold water was passed round the penis, to keep the parts cool and clean. 
If there was much ardor urinae, the patient was ordered to foment the 
part, and syringe with warm water every second hour. As soon as the 
ardor urinae abated, an injection of sulphate of zinc (gr. ij. ad 5J. aquae) 
was used four or five times a-day ; as the smarting in passing water 
abated, the proportion of sulphate of zinc was increased to five grains to 
the ounce. He then commenced bathing the parts with cold water, and 
took balsam of copaiba, turpentine, or cubebs. The patients were inva- 
riably confined to bed while under treatment, used only spoon meat or 
milk diet, and barley water for drink. Every third or fourth morning a 
dose of Epsom salt, with or without tartar emetic, was taken to keep the 
bowels free. In a few obstinate cases, injections of sulphate of copper or 
nitrate of silver were employed, with the occasional use of the bougie, or 
a small blister over the track of the urethra. 

From this simple but excellent and efficacious plan of treating gonor- 
rhoea, we come now to the treatment of chancre. This is a point deserv- 
ing of your attention, and peculiarly important with reference to the sub- 
ject at present under consideration. The patients, on admission, were 
purged with Epsom salt and tartar emetic, and were ordered to apply a 
bit of lint wet with a solution of sulphate of copper to the chancres, re- 
newing the application every second hour, and using the moistened roller 
to keep the parts cool and retain the dressings. Milk diet was prescribed 
as before, and a dose of salts, or salts and tartar emetic, taken every 
second morning. The parts were frequently bathed with cold water, par- 
ticularly if there was any pain in the groins, and the chancres were occa- 
sionally touched with nitrate of silver, or sprinkled with red precipitate to 
expedite the cure. Calomel was rarely given : and when administered, 
not for the purpose of affecting the mouth, but merely as an alterative, 
and in combination with tartar emetic. The men were all confined to 
bed, the most perfect cleanliness insisted on, and the bowels kept in a 
soluble state. 

Buboes were treated in a similar way, but with a more rigid observance 
of the antiphlogistic regimen. Buboes are often seen without any ulcers 
on the penis, or they have appeared after the ulcers have healed. They 
are constantly bathed with cold lotion, and by this means, aided by the 



262 CLINICAL MEDICINE. 

solution of tartar emetic and salts, they were frequently dispersed. If, in 
spite of these measures, they become enlarged, red, and tender, a warm 
poultice, three times a-day, and frequent fomentations, were employed. 
If there was still any chance of resolution, small doses of calomel and tar- 
tar emetic were administered, and the poulticing continued, care being 
also taken to keep up a loose state of the bowels by saline purgatives. In 
general, these means were followed by the desired effects. If, notwith- 
standing these measures, the buboes increased in size, became softer, and 
exhibited proofs of fluctuation, Dr. Roe opened them b\ applying the kali 
purum to the diseased surface. He then continued the fomentations and 
poultices, dressed the ulcer with red precipitate, and when it began to 
assume a healthy appearance, applied a compress and roller to keep the 
edges of the ulcer together, and keep down exuberant granulations. At 
the same time the patient took decoction of bark with sulphuric acid, or 
sarsaparilla with nitric acid ; these, with a more generous diet, and a 
moderate use of porter, generally succeeded in producing a speedy and 
permanent cure. 

Among all Dr. Roe's patients there was only one case of secondary 
syphilis. This man, who laboured under buboes at the time of his ad- 
mission was in bad health ; the buboes were extremely chronic, and dif- 
ficult of cure. He was treated during the winter, and returned, some time 
after being discharged, complaining of cough and sore throat, with a 
papular eruption over the breast, back and thighs. He was treated with 
alterative doses of calomel, combined with tartar emetic and opium, and 
used the warm bath three times a-week. His bowels were kept open, a 
generous diet, with porter, was allowed, and he took the decoction of 
sarsaparilla with nitric acid. He recovered completely, and is now stronger 
and in better health than he has been for many years. A solution of alum, 
as a gargle, and the use of volatile liniment, with flannel, externally, was 
all that was found necessary for the cure of his sore throat. He was about 
a month under treatment. 

Such was the plan of treatment followed by Dr. Roe, and that it proved 
eminently successful is shown by the result, for out of 231 patients, of 
whom 87 had chancre and 36 bubo, there was only one case of secondary 
syphilis. Of these facts I have been myself a witness, and they are cer- 
tainly of great importance. I do not think that more gratifying results 
could have attended the best-regulated mercurial treatment. I may ob- 
serve, however, that soldiers enjoy many advantages which civilians of 
the lower class are, in a great measure, deprived of. They are not left to 
their own discretion as to the time they should apply for advice, as to the 
mode in which they should conduct themselves during the course of treat- 
ment. Soldiers are generally inspected by the medical officer once a 
week ; the glans, prepuce, orifice of the urethra, and groins, are carefully 
examined, so that any trace of disease cannot escape detection. 

In this way the disease is attacked at its very commencement, and 
checked at once ; a circumstance which, for reasons hereafter to be ex- 
plained, has an important influence on the proportion of the cases of 
secondary syphilis. 

Again, during the process of cure, the men are not allowed to walk 
about, take exercise, indulge in the use of intoxicating liquors or stimu- 
lant diet, or expose themselves to the vicissitudes of the season. It may 
be also observed, that soldiers, from the care employed in the selection 



GONORRHOEA. 263 

of the recruits, from their mode of life, diet, exercise, and regular hours, 
are some of the healthiest members of the community ; and therefore 
enjoy, in a very remarkable degree, the advantage of resisting infectious 
diseases, or getting rid of them sooner than persons of feeble constitu- 
tion. 

There are some points in Dr. Roe's treatment to which I shall now 
advert. In gonorrhoea he begins, internally, with cooling antiphlogistic 
medicines, and afterwards passes to the use of internal stimulants. He 
also applies local antiphlogistic means in the commencement, directing 
the patient at first to syringe w 7 ith tepid water, which is exchanged for a 
mild astringent injection as soon as the ardor urinae abates ; and he after- 
wards employs stronger and more astringent injections. When neglect 
or an injudicious treatment have allowed gonorrhoea to attain the second 
stage (that of inflammation), it will be always right to apply the antiphlo- 
gistic method, generally and locally ; but this does not preclude the use 
of injections: they must be skilfully administered, for fear of injuring 
the inflamed urethra, and at first should merely consist of one drachm of 
mucilage dissolved in seven of water. After using this two or three 
times, one grain of sulphate of zinc may be added. On the morrow and 
day after the same may be continued, and then it may be rendered more 
active by increasing the quantity of sulphate, and adding other matters, 
of w T hich more hereafter. 

In order to prevent you from misunderstanding my meaning, it is ne- 
cessary to explain that gonorrhoea may be considered as exhibiting three 
different stages. In the first, immediately succeeding the period of in- 
cubation (during which the infection has as yet produced no perceptible 
symptoms), a very slight oozing of whitish mucus takes place from the 
urethra, and a little tingling is felt in that passage, whose mucous mem- 
brane then exhibits an incipient redness. No pain is felt in passing water. 
This stage seldom lasts more than two days; but occasionally it does. 
When gonorrhoea is to be violent, it is of short duration ; when mild, of 
longer. It passes gradually into the second or inflammatory stage, with 
its well-known projluvium, ardor u rinse, and other symptoms ; and this 
again, in due time, is succeeded by the third stage, or that of decline. 
The first and last stages are peculiarly suited for the employment of as- 
tringent injections. 

I do not know any practical point on which greater diversity of opinion 
exists than the administration of injections in gonorrhoea. In Dublin, 
students are generally taught that their use is improper and dangerous. 
The following are the chief objections to which they are said to be liable : 
— 1st. They do not diminish the urethral inflammation though they dry 
up the discharge, and consequently they lay the foundation for stricture, 
or more immediately occasion the inflammation to descend along the ure- 
thra, until it extends to the membranous portion, the prostate, or even the 
bladder. 2dly. Their use renders swelled testicle and sympathetic bubo 
more frequent. 3dly. It is argued that the use of any measures, except 
such as are purely antiphlogistic, must be improper in a disease accom- 
panied by so many indubitable signs of inflammation. Let us closely ex- 
amine this last objection, and we shall find it to possess more apparent 
than real weight, for analogy proves that the principle on which it depends 
is by no means universally applicable, particularly in cases of specific in- 
flammation. When surgeons placed their sole reliance on antiphlogistic 



264 CLINICAL MEDICINE. 

measures, local or general, in the treatment of purulent ophthalmia, the 
results were truly disastrous ; and however exhausted the patient became 
from excessive bleeding by the lancet and leeches, aided by large and 
frequently-repeated doses of tartar emetic internally, the local inflamma- 
tion proceeded in its rapid and destructive course, scarcely influenced, 
never effectually checked, by the treatment adopted. I have seen a man 
treated (in the Meath Hospital, by myself and the late able ophthalmic 
surgeon, Mr. Hewson) with bleeding, general and local, employed, I 
might say, to excess, and aided by rapid and profuse mercurial salivation : 
I have seen, in the patient referred to, both eyes destroyed by purulent 
ophthalmia in a few days. Not long ago, I was called during the night 
to visit a young gentleman in a hotel ; he had gonorrhoea, and went to 
bed without any complaint of the eyes, but was soon wakened by pain in 
the left eye. It was evidently purulent ophthalmia, and was cured in the 
course of a few hours by relays of leeches, and a strong sulphate of zinc 
collyrium, carefully applied. After thousands had lost their vision from 
the effects of this disease, it was at length discovered that some who 
adopted a totally different mode of practice, and who treated" the purulent 
ophthalmia in its very commencement with strong astringent and corro- 
sive applications, were eminently successful. This led many army sur- 
geons, more especially Mr. Guthrie, to investigate the subject with care. 
You are aware of the important practical results at which he arrived, and 
of the great improvement which has consequently<taken place in ophthal- 
mic surgery, leading to the application of solid nitrate of silver, or its 
concentrated solution, of sulphate of copper, &c, &c, to the mucous 
membrane of the eye in the first stages of purulent ophthalmia — a mode 
of treatment which our predecessors would not have hesitated to pro- 
nounce most hazardous and destructive. 

That astringent and stimulant collyria are applicable in the incipient 
stages of some other species of ophthalmia, as well as the purulent, is now 
familiarly known to surgeons. The following example of its utility 
occurs in a work lately published, on the Oases of the Libyan Desert, by 
Mr. Hoskins. It is necessary to remark, that the ophthalmia described 
by Mr. Hoskins. and so common both among the natives and foreigners 
in Egypt, is essentially a purulent ophthalmia, which, however, attacks 
with very different degrees of intensity, being in some mild and chronic, 
in others most acute, and suddenly destructive of vision. 

" Nov. 5th, 1832. — I was confined to my tent the whole of this day by 
a painful attack of ophthalmia ; and although in the morning it was very 
severe, yet by double doses of the contents of an inestimable bottle, I 
have nearly subdued it. As some of my readers may wish to know what 
this wonderful vial contains — what this infallible remedy for such a baneful 
complaint can be — I will tell the history of it, though I cannot fully gratify 
the desire of the curious. The purser of the French frigate, the Luxor, 
which was built for the purpose of removing one of the obelisks from 
Thebes, was the fabricator of this extraordinary water. He informed me, 
when in Egypt, that his father had been attached to Napoleon's expedition 
to that country, and had then discovered this miraculous cure. From 
fear of its being analyzed, he had never allowed any person to possess 
more than a very small quantity ; but he cured without fee all who came 
to him, Christian and Mussulman, French and English, Turk and Arab. 
When this liquor was applied in time, it was found always to stop the 



GONORRHOEA. 265 

most virulent attacks of the disease, and generally relieved in a very few- 
days even those who had been for several months martyrs to the complaint. 
A Turk, who had suffered for years, was completely cured in a fortnight ; 
and in gratitude to his benefactor, gave him a horse richly caparisoned. 
The Frenchman's fame was spread throughout the country, and many 
came to him as far as from Keneh and Esneh. Even the surgeon of the 
Luxor was so sensible of the value of the remedy, and of its producing 
no subsequent bad effects, that he sent all the officers and men of the 
vessel suffering from that complaint to the purser or to the hakim (doctor), 
as the natives called him. The application was easy to the hakim but 
most painful to the patient. He let fall a single drop of the water on the 
ball of each eye, which immediately spread, and from its pungent nature 
caused, if much irritation existed, the most inexpressible torture. In 
twenty minutes, or half an hour, this pain subsided, and a little clammy 
matter was seen to ooze from the eye. The remedy, although violent, 
did not weaken the eye in the slightest degree, nor in any manner injure 
the sight. Knowing that I purposed to go into Ethiopia, the hakim had the 
kindness to sell me, for about its weight in gold, a small bottle of this water ; 
but under the express condition that I would neither directly nor indirectly 
allow it to be analyzed. He said that it was his intention to return again 
to Egypt, and that he expected to be able to make his fortune ; but 
whether he does or not, I feel most grateful to him for having saved me 
from so much torture, as I have often been obliged to have recourse to 
the water, and have kept my promise in not allowing it to be analyzed. 
As this person has now left the country, and no further supply is to be 
obtained, I prize the water most highly, and cannot afford to use it for 
the relief of mere strangers. The remedy which we generally find to 
succeed with the natives, when applied to by them, is sulphate of zinc in 
strong doses — ten grains being dissolved in an ounce of water, and a drop 
of this being put in each eye two or three times a-day. This is by no 
means so certain a remedy as the hakim's water, but in nine cases out of 
ten I have found it to succeed. When, however, the inflammation and 
swelling are so great that the eyes are closed, cupping is the only effectual 
remedy. Mr. Ponsonby, who travelled with me in Lower Nubia, was 
attacked with this description of ophthalmia. He sent without delay for 
the hakim, alias barber, of the village. It was fortunate that the eyes of 
Mr. P. were quite closed, for had he seen the hakim he would scarcely 
have reposed sufficient confidence in his skill to submit to the opera- 
tion. The man was actually in rags, and of the most unprepossessing 
appearance, without a single ray of intelligence in his countenance. 
His cups were made of the horns of a cow, and his instrument was an old 
razor, not so decent-looking nor so sharp as a tolerably good stick knife. 
I offered him a lancet, but he said that he did not know how to use it. 
Thinking that it would be less painful for Mr. P. to be sacrificed with a 
sharp than a blunt razor, I gave the man one of my own ; but being unac- 
customed to so fine an instrument, and not aware of the much less force 
it required than his own blunt knife, he cut too deep ; I therefore thought 
it best to allow him to finish the operation in his own way. I must con- 
fess, indeed, that he did it very expertly, and I may add successfully ; as 
he effected a very sudden and almost miraculous cure of Mr. P.'s oph- 
thalmia. At Thebes I had two severe attacks of this disease, which 
incapacitated me from either reading, writing, or drawing. Thanks to 



266 CLINICAL MEDICINE. 

the hakim's water, these attacks were fortunately short; but they were 
painful while they lasted, and most irksome to support. To be debarred 
from all mental enjoyment and bodily exercise — to be in the world and 
yet see nothing; and to be without the general resources of the blind, 
particularly society, this was indeed tiresome. A Turk might probably 
have amused himself with his beads, but even a Mahoraedan's philosophy 
would have forsaken him in such a situation, especially as the regimen 
necessary for this complaint requires the sacrifice of the all-consoling pipe. 
The Arabs and Turks having frequently asked me for medicine to relieve 
them from attacks of ophthalmia, the water that I applied to their eyes 
invariably caused them extreme pain ; which, however, they bore with 
great courage and resignation, having implicit faith in the skill of a 
European. When, however, I desired them to give up their pipes 
(smoking being extremely injurious), u Inshallah !" (please God!) they 
replied, but never had the resolution to do so. An opium-eater may 
refrain from his weed, a drunkard may resign his glass ; but I soon found 
the absurdity of asking an Oriental to abandon his shibouk. Like ice to 
the Sicilians, macaroni to the Neapolitans, and grog to the British sailor, 
they consider it as their staff of life, and conceive it impossible to get 
through the day without it." 

With respect to the objection that the treatment of gonorrhoea by injec- 
tion lays the foundation for strictures, I beg most distinctly to deny the 
truth of the assertion ; whatever diminishes the intensity, and shortens the 
duration of the urethral inflammation, must tend to diminish, and not to 
increase, the liability of strictures. Compare the violence and duration 
of a gonorrhoea skilfully treated from its very beginning, by injections, 
with a case where no injections are employed — the physician's reliance 
being exclusively placed on perfect rest, confinement, fasting, and cooling 
medicines ; compare two such patients, observe how the one is perfectly 
cured of his disease in a few days, without confinement, and without any 
deviation from his usual diet and habits (I speak now of two cases coming 
under treatment in a day or two after the appearance of the very first 
symptoms) ; and then watch the other through sufferings protracted week 
after week, until his constitution is debilitated by confinement and low 
diet : how often do we find the discharge from the urethra increasing 
daily, in spite of the general and local antiphlogistic remedies employed, 
until it is profuse in the extreme, and accompanied by great ardor urinae, 
painful erections, irritation of the bladder, and chordee. Now I will fear- 
lessly assert that a medical man who gets the care of a recent gonorrhoea 
in a healthy constitution, is grievously to blame if he permits this series 
of bad symptoms to supervene. 1 do not deny that these symptoms will 
at length give way to the antiphlogistic treatment, leeches along the peri- 
naeum, stupes, inunction of the skin covering the urethra, with mercurial 
ointment and belladonna, &c, &c. These remedies will in the end get 
rid of the disease, but then at what a loss of time and strength ! I again 
repeat the assertion, and I do it emphatically, that a gonorrhoea treated by 
injections from the beginning, can generally, in persons of sound constitu- 
tion, be cured in a few days. When a gonorrhoea has been allowed to 
continue several weeks, it often so alters the vitality, and probably the 
structure of the affected tissues, that a cure is uncertain, and frequently 
the treatment becomes both perplexing and tedious ; when a gleet super- 
venes, then remedies even the most judiciously selected frequently fail 



GONORRH(EA. 267 

altogether : these facts prove the necessity of curing the disease, in every 
instance, as soon as possible. 

But, gentlemen, we must here enter into details, and first as to the 
manner of injecting the urethra. Many believe that the inflammation 
produced by the specific poison of gonorrhoea is seated chiefly, if not ex- 
clusively, in the portion of the urethra near the orifice ; and hence they 
are only anxious to introduce the injected fluid a short distance in that 
canal. Nothing can be more unfounded than this opinion, and nothing 
more injurious than the practice to which it gives rise. The inflammation 
which gonorrhoea produces in the urethra is by no means confined to the 
third of the canal near its orifice, but even in recent cases it extends much 
farther, and it cannot therefore be efficiently treated by injections, which 
do not come into contact with the whole extent of inflamed surface. Un- 
less you yourselves teach your patients how to inject, not one in ten of 
them will do it properly. Of this, an extensive experience has convinced 
me. Over and over again have I been told that there was no use in try- 
ing injections in a particular case, as they had been already tried in vain; 
and on accurately inquiring into the patient's mode of injecting, the result 
has been the discovery that he was quite ignorant of the proper method. 
The pewter syringe or squirt used must be in proper order, so as to work 
easily with the pressure of one finger ; otherwise when the end is in the 
urethra, and the patient tries to inject the fluid contained in the syringe, 
the point is very apt to be hitched against the urethra, in consequence of 
the force thus suddenly applied. The point of the syringe must be care- 
fully introduced at least half an inch within the lips of the urethra, and the 
forefinger and thumb of the left hand must then be so applied as to press 
the lips of the urethra gently on the syringe, so as effectually to prevent 
the reflux and consequent escape through the orifice, of the injected fluid. 
When the fluid is thrown in, the patient will feel it in the urethra, which 
it will gently distend as far down as the membranous portion, if a suffi- 
cient quantity be injected. Some persons have an idle fear about the ill 
consequences which would arise were any of the injection to arrive at the 
bladder. An ordinary pewter syringe does not contain more than a 
drachm and a half, which is about the quantity required for one injection. 
When the fluid has been injected, the point of the syringe is to be with- 
drawn, and the lips of the urethra kept closed with the finger and thumb, 
for at least two minutes, when, the pressure being removed, the injected 
fluid will be thrown out from the urethra with considerable force, in con- 
sequence of the elasticity of that canal. These directions, gentlemen, 
are by no means unnecessary ; indeed, I never treat a patient without 
seeing that he knows how to inject, for I find that many say they know 
the right method, who are quite ignorant of it, and who consequently do 
themselves more harm than good by making the attempt. 

It is not my object to enter at present into the especial therapeutics of 
gonorrhoea, and consequently it would be foreign to my plan to speak of 
the various substances which may be used in injections ; for an account 
of these I must refer to authors who have written at large on these sub- 
jects. As a general rule, you ought to commence with weak solutions of 
the astringents you prefer, which solutions may be used five or six times 
a-day, and may be daily increased in strength. An injection should sel- 
dom be used so strong as to cause at the time any thing like severe pain of 
the urethra. In this respect we must not closely imitate the example of 



268 CLINICAL MEDICINE. 

eye-waters, such as that used by the Egyptian hakim. I have, indeed, 
often known very strong injections used at the first trial, and which, though 
they produced great pain for many minutes after their introduction, yet 
were very effectual in rapidly curing the disease, and that without any 
bad consequences. (This is more especially the case with nitrate of sil- 
ver, which, although a powerful remedy, I have found unmanageable, 
and therefore not to be recommended.) Still, however, by far the safer 
and more prudent practice is to commence with astringent injections, so 
weak that, when used, they may produce merely a sense of titillation, or 
of very inconsiderable smarting. It is often difficult at first to hit off, if 
I may use the expression, the precise strength required ; and therefore I 
always give my patients particular instructions, and desire them, if the 
injection is at all too irritating, to dilute it with water to the desired de- 
gree of strength. The sensibility of the urethra diminishes very rapidly 
when an injection of proper strength is applied to the inflamed surface, so 
that the solution maybe daily rendered more astringent. I have told you 
that astringent injections are suited to every case of gonorrhoea at the 
commencement of the disease, and that, when properly used during the 
first, second, or third day, they almost always cut it short. It is not so 
when the disease has attained its acme, and the inflammation is at its 
height, accompanied by profuse discharge, chordee, &c, &c. Even 
then, however, injections properly managed will tend to assist the local 
antiphlogistic measures; but in such cases we must always commence by 
using more mucilaginous warm water, and must add the astringents at 
first very sparingly, and must increase their proportions very cautiously. 
I omitted to observe, that always, before using an injection, the patient 
ought to clear the urethra by voiding a little urine. Such directions, gen- 
tlemen, may appear to many prolix and unnecessarily minute ; but not 
knowing any author who has condescended to give accurate accounts re- 
specting these matters, I have thought it my duty to lay them before you, 
being convinced of their utility. 

Before I conclude, it is right to put you on your guard about the mis- 
chief which may ensue if you attempt to prescribe astringent injections 
during the secondary or inflammatory stage of gonorrhoea, without pre- 
viously having ordered such general and local antiphlogistic treatment as 
is required to diminish the existing inflammation ; nor will even this be 
sufficient to insure success, unless you take care that your patient remains 
quietly at home for a few days, and observes a spare vegetable diet. A 
person who will not follow your directions in these matters, cannot use 
astringent injections during this stage of the disease with benefit or even 
impunity. In the first stage, and in the third, it is not absolutely neces- 
sary to enjoin rest and abstinence ; it is, indeed, better and more prudent 
that the patient should remain in his room, and should observe low diet 
for a day or two ; but in some cases this is impracticable, and then he 
must, as far as possible, avoid stimulant food and much walking exercise. 



GONORRHOEA. 269 



LECTURE XXV. 

Gonorrhoea — Injections, combined with general and local Antiphlogistic Means — Gonorrhoeal 
Rheumatism and Ophthalmia — Postscript. 

Gentlemen, — In the remarks I have hitherto made on gonorrhoea, I have 
merely sought to elucidate its general pathology and treatment, and, ac- 
cordingly, have avoided all details connected with complicated cases, 
where the disease does not occur in its simple form in a constitution and 
urethra previously sound. 

Where strictures, and previous diseases of the urethra, bladder, or 
prostate, exist, the simple treatment I have recommended is no longer 
applicable ; and the same observation applies to eases badly treated, 
neglected, or of long standing, and to patients with a weak or scrofulous 
constitution. 

At our last meeting we spoke of the mode of using injections : to-day 
I shall add a few particulars concerning their strength. We should trust 
in the beginning to weak solutions, such as one or two grains of sulphate 
of zinc to the ounce of water: which may be used five or six times in 
the day. When we increase their strength they must be employed less 
frequently. It is seldom necessary to use a solution stronger than three 
grains to the ounce. I am in the habit of employing such a solution 
combined with one or two drachms of mucilage, and about ten grains of 
prepared Lapis calaminaris in powder ; the mucilage veils the astringent 
and irritating qualities of the metallic salt, and renders it more likely to 
become entangled and be detained in the urethra. How the Lapis cala- 
minaris acts, unless on a mechanical principle, it is difficult to explain ; 
but of its utility I am certain, having long used this combination, as re- 
commended in Thomas's Practice of Physic. Some add a little balsam 
of copaiba ; but it has the disadvantage of betraying the patient's secret 
by its odour. 

As I am now only engaged in explaining the general principles on 
which the cure is to be conducted, I need not enumerate the great variety 
of astringents which may be employed. One important piece of advice 
I can give you on this point is, to confine yourselves, as far as possible, 
to the use of the same astringents. Two or three will suffice for all neces- 
sary combinations. By doing this, you will become accustomed to their 
effects, and will, by habit, be enabled With great accuracy to judge 
whether it is proper to increase or diminish the strength of the solution 
in any particular case. 

Another rule of practice is, that you must make the patient leave off 
injecting at intervals, say every second day, for a certain number of hours, 
for instance twelve, before you examine him, in order that the immediate 
effects of the astringent may have subsided so far as to allow you to esti- 
mate the actual state of the disease. It often happens that the improve- 
ment is scarcely perceptible, until the injections have been intermitted. 
This observation leads to another rule, viz., that w r hen you are using 
strong injections, and have made an evident impression on the disease, 
you may leave "them off every second or third day, according to circum- 



270 CLINICAL MEDICINE. 

stances, so as to insure their not being continued beyond the time they 
are actually necessary. With these precautions, I can confidently recom- 
mend the use of injections, and maintain that they do not render the 
patient more than usually liable to strictures, sympathetic bubo, or swelled 
testicle. 

Strictures often occur in men who have never had a gonorrhoea, and 
swelled testicle and sympathetic buboes are frequently met with in cases 
of clap, where injections have not been used at all. I do not mean to 
deny that injections, imprudently or unskilfully managed, may give rise 
to these accidents. Of this there can be no doubt, nor is the cause very 
obscure ; for we can readily conceive that an injection, ill adapted to the 
sensibility of the parts, may increase the urethral inflammation. Of all 
matters recommended for injections, the nitrate of silver seems most liable 
to this objection. 

When gonorrhoea degenerates into gleet, which it is most apt to do in 
badly treated cases, and particularly in scrofulous habits, the cure is 
uncertain and troublesome ; but as I have nothing to add to the practical 
precepts which your class-books contain on the subject, I shall not detain 
you by any further observations. 

With respect to the gonorrhoea! virus, I entirely concur in the modern 
opinion, recently confirmed by the experiments and inoculations performed 
by Ricord, that the poison which causes clap is different from that which 
gives rise to chancre, and secondary symptoms ; and that, consequently, 
it is quite unnecessary to make use of mercury in order to guard against 
constitutional sequelae. 

It is well that practical men have at length made up their minds upon 
this subject. Twenty years ago, when I commenced practice, we often 
concluded the cure of a gonorrhoea by a fortnight's course of morning and 
evening inunctions, employed for the purpose of protecting the patient 
against the danger of secondary symptoms. 

Ricord employs injections of zinc, or lead, or nitrate of silver, in gonor- 
rhoea, as soon as the acute stage has been removed, or its violence 
diminished by rest, antiphlogistic regimen, and twenty or thirty leeches 
to the perinaeum. He seems to employ the astringent injections generally 
after three or four days of antiphlogistic treatment, or from the very be- 
ginning, where the inflammation is slight. My experience has amply 
confirmed the assertions of our predecessors, that the same astringent 
applications which are proper after the diminution of the urethral inflam- 
mation, are also proper before it has completely formed itself. I should 
not have entered so largely on this subject, were I not aware that many 
practitioners condemn the use of injections altogether, and trust to rest 
and antiphlogistic measures alone — a method of treatment not only tedious, 
but in many respects most injurious. 

It may be well to remark, that for many years I have not, in recent and 
uncomplicated cases, ordered cubebs, copaiba, or any such medicines 
internally, having succeeded to my entire satisfaction in the treatment 
of gonorrhoeal patients by means of general and local antiphlogistic mea- 
sures combined with injections. I differ in one point, and one only, from 
Ricord, who always begins by employing the anti-inflammatory diet and 
treatment. I have no objection to his method, except the inconvenience to 
which it necessarily puts the patient ; for the loss of a few days, and con- 
finement to his room, would in ordinary diseases, be of trifling conse- 



GONORRH(EA. 271 

quences ; but in cases like the present the patient is always most anxious 
to avoid measures which could not be adopted without exciting suspicion. 

To such an anxiety I would never yield, when my so doing could in 
the slightest degree retard or compromise the safe and speedy cure of the 
disease, neither of which risks are incurred by the prudent application of 
the plan I have recommended for the treatmentof nascent gonorrhoea, and 
which -is sanctioned by older writers, although repudiated and censured 
by the modern antiphlogistic school. 

There are two affections said to be connected with gonorrhoea and 
which consequently demand some consideration. I mean ophthalmia 
and arthritic rheumatism. There are many and highly re>pectable au- 
thorities in favour of the existence of such a disease as gonorrhoeal rheu- 
matism. Bacot says that the most usual form consists in a painful 
and swollen state of the knees and ankles, which seldom comes on until 
the decline of the gonorrhoea, and is most commonly met with in young 
men of a florid complexion and a delicate strumous habit ; the articular 
affection is sometimes suddenly relieved by the appearance of an eruption 
of papulae in clusters, or of pustules in very minute patches. 

Vetch describes this form of rheumatism as most intractable ; I must 
refer you to his work and Bacot's for an account of the proper treatment, 
as I have not myself had sufficient experience in the disease to enable me 
to speak decidedly on the subject. Very lately I saw with Dr. Nalty, of 
Clare Street, a gentleman about 35 years of age, who was afflicted with 
his fourth gonorrhoea, and in whom the ardor of symptoms was very re- 
markable and deserving of notice. In him each gonorrhoea ran the usual 
course until the period when the running and urethral inflammation began 
to decline; then invariably (and that each of the four times he was at- 
tacked) his eyes became very painful, red, watery, and intolerant of light, 
presenting at first all the appearance of simple acute conjunctivitis the 
result of cold. The conjunctiva covering the sclerotic soon became very 
much affected, but exhibited no tendency to secrete pus or become 
swollen, so as to form chemosis. In these important particulars the in- 
flammation manifestly differed from the purulent form. In a few days 
the sclerotic, and afterwards the internal tissues of the eyeball, were in- 
flamed, and vision thus seriously impaired for. the time. It does not, 
however, appear that the pupil was ever disfigured or the iris engaged, 
so far at least as concerns its margin and anterior surface. The redness 
of the eyeball was diffused and general, and not restricted, as in some 
cases of true internal syphilitic ophthalmia, to a zone at some distance 
from the cornea. This ophthalmia required very active local depletion, 
and yielded to treatment with much difficulty. 

At our second visit we found that a very minute ulcer had formed on 
the cornea. The measures advised consisted of colchicum internally, 
slight scarifications of the inner surface of the lower eyelid, and on the 
next day a drop of the solution of nitrate of silver, four grains to the ounce, 
to be applied to the eye itself. 

It is to be particularly remarked, that during the increase and acme of 
the ophthalmia, the urethral discharge was always lessened, but by no 
means cured ; and if at any time this discharge increased, an immediate 
diminution of the violence of the ophthalmia ensued. On this point our 
patient was quite clear. So far, then, respecting the ophthalmia ; let us 
now follow the further development and succession of symptoms. 



272 CLINICAL MEDICINE. 

Invariably after the ophthalmia had lasted for some days, one or other 
of his joints became affected with very acute inflammation, and when this 
was about to subside in the joint first attacked, a new inflammation was 
set up in some other joint; thus the knees, ankles, elbows, &c, became 
successively and violently engaged, each in its turn being red, tender, 
painful, hot, and refusing to allow its ordinary motions. The arthritic 
inflammation was sometimes so violent as to leave an impairment of mo- 
tion, and a stiffness of the joint, which continued for months after he had 
otherwise perfectly recovered. When I saw him he had sciatica of the 
left leg, as well as the usual arthritis. 

This case, gentlemen, is very instructive, and proves beyond a doubt 
the existence of an arthritis and an ophthalmia, the consequence of a gonor- 
rhoea; as the ophthalmia had all the characters of rheumatic ophthalmia, 
we must attribute its origin to an impression made on the constitution by 
the gonorrhoea ; here, as the articular inflammation and the ophthalmia 
had one and the same character, and as the affection of the joints could 
not of course be produced by contact of the urethral discharge, we must 
admit that this could also have nothing to do with causing the inflamma- 
tion of the eye. This is important, and demonstrates that at least one 
species of ophthalmia is caused by gonorrhoea independent of direct in- 
fection. The existence of sciatica is also very remarkable. 

Sir Philip Crampton, who afterwards saw this case in consultation, says 
that he has met with several similar, and he is of opinion, that some of 
them essentially consisted in a gouty inflammation of the eye and joints, 
excited and called into action by the gonorrhoea. 

Sir A. Cooper, who was the greatest of British surgeons, says, that 
gonorrhoeal rheumatism is not an unfrequent disease. He describes a 
case very similar in details to that I have already laid before you : — " I 
will give you," says Sir Astley, " the history of the first case I ever met 
with ; it made a strong impression on my mind. An American gentleman 
came to me with a gonorrhoea, and after he had told me his story, I smiled 
and said — do so and so — (particularizing the treatment), and that he 
would soon be better; but the gentleman stopped me, and said, " Not 
so fast, sir ; a gonorrhoea with me is not to be made so light of — it is no 
trifle ; for in a short time you will find me with inflammation in the eyes, 
and in a few days after I shall have rheumatism in the joints ; I do not 
say this from the experience of one gonorrhoea only, but from that of two, 
and on each occasion I was affected in the same manner." I begged 
him to be careful to prevent any gonorrhoeal matter coming into contact 
with the eyes, which he said he would. Three days after this I called 
on him, and he said, " Now you may observe what I told you a day or 
two ago is true." He had a green shade on, and he had ophthalmia in 
each eye ; I desired him to keep in a dark room, to take active aperients, 
and apply leeches to the temples. In three days more he sent for me 
rather earlier than usual for a pain in one of his knees ; it was stiff and 
inflamed ; I ordered some applications, and soon after the other knee be- 
came affected in a similar manner. The ophthalmia was with great diffi- 
culty cured, and the rheumatism continued many weeks afterwards. This 
case struck me very forcibly, and I asked Mr. Cline whether he had ever 
seen the rheumatism proceeding from gonorrhoea, and he replied, several 
times. The next case did not surprise me so much, and now and then, 
ever since, I have met with similar ones. It is by no means an unfre- 



GONORRH(EA. 273 

quent occurrence for gonorrhoea to produce a rheumatic and painful affec- 
tion of the joints ; whether it be by the absorption of the poison, or the 
constant irritation produced by the irritation of the urethra, I do not know, 
but certain it is that gonorrhoea produces ophthalmia and rheumatism, 
and that when not a single drop of matter has been applied to the eye. 
The inflammation generally attacks both eyes, and is of long duration ; it 
requires the same remedies as are used in gonorrhoea ; balsam of copaiba 
or some form of turpentine, must be exhibited ; either the spirit of tur- 
pentine, balsam of copaiba, or olibanum. I do not recollect to have met 
with a description of it in any surgical work, but whoever has practised 
at all must have frequently met with it." 

Such, gentlemen, is the information which this celebrated man has 
given us on this subject. From this it is quite clear that he does not de- 
fine or point out the different species of gonorrhceal ophthalmia and their 
different exciting causes ; neither is his description of the American's sore 
eye very full and explicit; it is enough so, however, to prove that his 
ophthalmia was not purulent, but rheumatic. 

It does not seem necessary to assume the absorption of any poison to 
account for arthritis and ophthalmia occurring in gonorrhoea. Of all parts 
of the body the joints are most liable to be associated in inflammation 
with distinct parts, and hence ordinary arthritis so often gives rise to peri- 
carditis, hepatitis, ophthalmia, &c. &c. We do not think it necessary to 
assume the absorption of poison when a urethral stricture occasions ague — 
an occurrence quite as remarkable as the production of arthritis by go- 
norrhceal irritation of the urethra. 

When any important part of the body becomes inflamed, there is no 
saying in what organ diseased action may commence as a consequence. 
Thus I have seen an inflamed state of the oesophagus, caused by a clumsy 
probang roughly passed, give rise to inflammation of the mucous mem- 
brane of the bladder. 

When Sir Astley Cooper published his Lectures in 1823, the subject of 
gonorrhceal ophthalmia had not received the attention its importance merits, 
and opinions of surgeons were very varied and contradictory, of which I 
can offer no stronger example than the fact, that in part of that very course 
of lectures, Mr. Green, who lectured for a time during Sir Astley's ab- 
sence, expressed himself in a manner quite opposed to the opinion of Sir 
Astley, who had said that gonorrhoea is capable of producing an ophthal- 
mia through the medium of the constitution. In fact, gentlemen, nothing 
satisfactory was published on gonorrhceal ophthalmia until Mr. Lawrence's 
Treatise on the Venereal Diseases of the Eye appeared in 1S30, of which 
work 127 pages are occupied with a description of the three different 
species of gonorrhceal ophthalmia, with numerous cases. 

This distinguished surgeon and physiologist has done more than all 
w T ho preceded him to illustrate his subject, and I most cordially recom- 
mend to your attention the above invaluable treatise. He denies (and in 
this I agree with him) the assertion, hereinafter to be noticed, that the 
matter from a gonorrhceal urethra cannot by contact produce disease in 
the eyes of the patient himself, and he brings forward many examples to 
prove the contrary. He divides the disease into three species: — 1st, 
acute or purulent and destructive gonorrhceal inflammation of the con- 
junctiva ; 2d, mild gonorrhceal inflammation of the conjunctiva; 3d, 
gonorrhceal inflammation of the external tunics and iris. 
19 



274 CLINICAL MEDICINE. 

It is of importance to recollect that this latter species does not exactly 
deserve the name of metastatic, for it often comes on without any, or, at 
least, a very partial subsidence or diminution of the urethral discharge. 

Some authors, as Scarpa, Boyer, Pearson, and Beer, deny the possibi- 
lity of a severe purulent ophthalmia being caused by the contact of any 
gonorrheal fluid, and assert that its application to the eye merely gives 
rise to a trifling and temporary irritation. More recent writers do not, 
however, acquiesce in this opinion. Thus, Mr. Middlemore sums up the 
matter with the two following conclusions: — " 1st. That by far its most 
usual mode of production is by the contact of gonorrheal matter, pro- 
ceeding from the urethra or vagina of some other person, not from that 
of the individual himself. 2d. That it is extremely improbable that any 
individual can communicate the disease from his urethra to his conjunctiva, 
by touching the latter membrane with the gonorrheal discharge." 

Were this latter position established on a secure and firm basis, I would 
regard it as one of the most interesting and curious results of modern in- 
vestigation. I must, however, confess, gentlemen, that I feel very doubt- 
ful of its accuracy, and that for the following reasons: — Inlhe first place, 
I have seen a case where a gentleman was most probably infected with 
purulent ophthalmia, in consequence of matter from his own urethra being 
brought into contact with his eye. I say most probable, for the nature of 
•the case almost necessarily precludes the attainment of certainty with re- 
gard to such matters, for very obvious reasons. In the second place, 
Ricord's experiments proving the facility with which a chancre can be 
produced in any part of the skin by means of matter taken from a chancre 
in the same individual — these experiments, I say, throw a heavy shade of 
doubt on the probability of the general doctrine, that an infectious fluid 
produced by one part is innoxious to the same person in other parts. 

The poison of itch manufactured by one part of the skin is often trans- 
ferred by the nails to another part, and the clothes worn by an itchy pa- 
tient are capable of not only producing the disease in another, but in him- 
self when cured. Many other similar examples might be brought for- 
ward, but enough has been said to show that the general analogy is not 
favourable to an opinion which I cannot help thinking has been founded 
on facts and experiments not sufficiently numerous or varied. Dr. Vetch, 
indeed, "took matter from the eyes of persons labouring under acute pu- 
rulent ophthalmia, and applied it in each case to the urethra of the same 
individual. No disease was excited. But when he applied the same mat- 
ter to the urethra of a different individual, it produced a violent gonor- 
rhea ; hence he argues that a person cannot infect himself, but may ano- 
ther." 

You observe, gentlemen, that this is pre-eminently a practical question; 
for if we agree in Dr. Vetch's conclusion, it is quite needless to impress 
on our gonorrheal patients the necessity of scrupulously guarding against 
the danger of infecting their eyes by the matter secreted by their urethras. 
Where the danger is so great, and where, should such an infection be pos- 
sible, the loss of one or both eyes may be the result, I would never trust 
to mere habits of cleanliness ; I would enforce them by the fears of infec- 
tion. 

With respect to the production of a violent and destructive purulent 
ophthalmia, in consequence of the application of gonorrheal matter to the 
eye, there can be no doubt whatsoever. Mr. Lawrence cites many exam- 



GONORRHOEA. 275 

pies, and I have seen several. Thus, some years ago, a poor woman made 
use of a vessel soiled by gonorrhoeal matter, to wash her own face and two 
of her young children. They all got purulent ophthalmia, and two left this 
hospital blind. On the whole, gentlemen, I think that we can very 
safely draw the following conclusions concerning gonorrhoeal ophthal- 
mia: — 

1st. A species of severe ophthalmia may be produced through the me- 
dium of the constitution, in persons liable to gonorrhoeal rheumatism or 
arthritis. This species attacks the conjunctiva, sclerotica, and internal 
tissues, and resembles gouty and rheumatic ophthalmia. 

2d. Another dreadfully violent species of ophthalmia is produced by 
the contact of gonorrhoeal pus. This closely resembles Egyptian oph- 
thalmia. 

3d. It is probable that another and a much milder species of conjunc- 
tivitis is produced by the contact of gonorrhoeal discharge of less violence ; 
and such was the opinion of the celebrated Beer. The fluid taken from 
the variolous pustule or the vaccine vesicle during their early stages will 
not communicate their proper infection ; in the same way the discharge 
from an incipient or declining gonorrhoea may act very differently on the 
eye from the puriform fluid secreted by the urethra during the acme. The 
only doubt which remains on my mind with respect to this milder con- 
junctivitis is, whether it, too, may not be produced through the constitu- 
tion. We have seen that a violent ophthalmia and arthritis may thus 
arise, and consequently we can easily imagine it possible for the same 
cause to give rise to a constitutional impression capable of originating a 
mild ophthalmia unaccompanied by arthritis. 

In the gentleman whose remarkable case I have related, and who was 
once treated for the ophthalmia by Mr. Wardrop, the very first gonorrhoea 
he had, ended in the formation of bad deep-seated stricture, although the 
plan of cure adopted had been from the beginning antiphlogistic, and he 
had been confined to bed for the greater part of the time, and kept on low 
diet, on account of the arthritis. This, with numberless other similar facts, 
proves that the chances of stricture are augmented by whatever prolongs 
the duration of the urethral disease, particularly in strumous habits, such 
was that of the gentleman referred to. No doubt, injections injudiciously 
applied, may increase or prolong urethral disease, and thus occasion stric- 
tures ; but if they diminish or cut short inflammation, I cannot conceive on 
what principle they can originate strictures. 

Postscript. — Since the preceding remarks on purulent ophthalmia were 
prepared for the press, I have conversed with Dr. Staunton, who accom- 
panied Colonel Chesney in the celebrated expedition to the Euphrates: 
Dr. Staunton says that in Egypt acetate of lead, under the name of English 
sugar, is in great request for making eve-water. The late essay, by Mr. 
Tyrrell, on a peculiar operation successfully employed by him to prevent 
destruction of the cornea in violent purulent ophthalmia, is of the greatest 
importance, and well worthy of attention, for it must be confessed that 
hitherto, when intense, this disease has baffled every effort of art, unless 
it happened to be placed under treatment within a few hours from its first 
appearance — a very rare occurrence indeed. A remarkable confirmation 
of the rationale of Mr. Tyrrell's operations may be found in a paper, pub- 
lished by Mr. Griffiths, in the Calcutta Medical Transactions, on a similar 



276 CLINICAL MEDICINE. 

mode of operation resorted to by the modern Persians in chronic opacity 
of the cornea. 

Having mentioned the discoveries of Ricord in the preceding lecture, 
I think myself bound in justice to the character of the late Mr. Wallace, 
of Dublin, to state that the latter gentleman has claimed all or nearly all 
Rieord's alleged discoveries. Mr. Wallace published in the London 
Medical Journal for November 16, 1833, a paper entitled " The discove- 
ries of Dr. Ricord, of the Hopital des Veneriens, of Paris, respecting the 
Venereal Disease, claimed by William Wallace," &c. &c. 

In this paper Mr. W T allace goes seriatim through the whole list of Ri- 
cord's discoveries, and proves that he had anticipated Ricord in all and 
each. As the question is one of great importance, it would be well to in- 
vestigate the matter a little more closely ; this I have not time to do my- 
self, but to facilitate the matter to others, I send Mr. Wallace's reclama- 
tion, which the editor of the Medical Gazette may perhaps judge it right 
to publish on a future occasion, with remarks on the subject. 

The application of escharotics to the eye in purulent ophthalmia w T as 
first introduced into practice by my late esteemed friend Surgeon Melin, 
of Malta, in 1811. The same plan was afterwards most extensively tried 
by Dr. O'Halloran, at Gibraltar; both wrote of this, plan long before it 
obtained the advocacy of Mr. Guthrie, whose reputation soon brought 
it into general use. In Dr. O'Hallaron's work, published in 1824, he 
makes the following observations: — u A solution of lunar caustic of ten 
grains to an ounce of water, is an excellent remedy in purulent ophthalmia. 
It may be used at all periods, and, next to the bluestone, claims prece- 
dence over all others. Its action, when resorted to at an early period, 
tends to change and lessen the discharge, and to remove the pain and 
irritability without causing any of the unpleasant symptoms which have 
been attributed to its use." 



LECTURE XXV. 

On the pathology and treatment of syphilis. 



Gentlemen, — The pathology and treatment of the venereal disease 
have engaged the attention of our ablest men since the days of Hunter, 
and have of late years, as you are all aware, undergone considerable mod- 
ification and improvement. Still, however, much variety of opinion exists 
respecting both these subjects, as may be proved by the following facts : 
in this city, for instance, Mr. Colles and Mr. Carmichael profess opinions 
very different from each other, and the high reputation these distinguished 
surgeons enjoy, insures to each a numerous host of followers ; we have 
here consequently, two rival schools, whose teachers disseminate opposing 
doctrines. This want of fixed opinion is felt in London as well as Dublin, 
and displays itself in a not less marked manner amongst the practitioners 
of Paris, Hamburgh, Vienna, and Berlin. If you compare together the 
modes of practice pursued by that highly-instructed and intelligent class 
of medical men — the surgeons of the British army — you will find the 
same want of unanimity, and consequently the inmates of the venereal 



SYPHILIS. 277 

wards of one regiment are often treated in a manner the very reverse of 
that pursued by the surgeon of the other regiment stationed in the same 
barrack; of which I have seen some striking instances in the Dublin gar- 
rison. Matters are quite as bad in the Prussian army. In a letter which 
I lately received from Dr. Robert Froriep, the distinguished pathologist 
of Berlin, he says, " I have taken advantage of the vacation to examine 
the Medical Reports of the Army, having obtained the kind permission of 
the physician-general, Doctor Lohmeier, for that purpose, but I could not 
make out any thing likely to assist you in your researches ; in fact, these 
documents furnish data apparently the most contradictory. Thus, one 
report praises the mercurial, and another the non-mercurial treatment ; 
while in almost no case do we find the symptoms, treatment, and results, 
detailed with sufficient precision to enable us to arrive at any thing like 
satisfactory conclusions." 

In the following lectures I do not propose to solve the difficulties 
which embarrass this important question, neither do I come forward as an 
advocate on either side ; my time is too much occupied to allow an ex- 
amination of this subject in all its details ; and without such an examina- 
tion it would be premature, nay, impossible, to arrive at a satisfactory 
conclusion. My object in touching on the matter is less ambitious; and 
I come forward merely as a contributor of materials, chiefly derived from 
German sources, and partly my own ; which materials may perhaps prove 
useful to others employed in the elucidation of this important subject. 
From an extensive correspondence with practitioners in various countries 
of Europe, I find that every where a great division of opinion exists ; and 
we have reason to believe the same of North America. In the latter 
country, however, the non-mercurialists are gaining ground, as appears 
from articles published in the American journals. Under these circum- 
stances, and in this embarrassed state of opinions, some attempt ought to 
be made to obtain more accurate data. If the matter was taken up, as 
its importance deserves it should be, by some medical body or association 
of eminence, individuals might be encouraged to inspect the chief hospi- 
tals of Europe and America, and thus obtain accurate information. Were 
application made, from a proper quarter, to the heads of the medical de- 
partment in the English, French, Prussian, and Austrian armies, it would 
no doubt elicit much important matter: such an application, coming from 
the Medical Section of the British Association for the advancement of 
Science, could not fail. Until some public body, or some enterprising 
and zealous individual, collects from every quarter that information which 
is so easily attainable on the spot, but so difficult to acquire at a distance, 
this great practical question must still remain unsolved ; for its solution 
will be only then possible when the results of the opposing methods have 
been ascertained and contrasted, in various climates and among various 
races of mankind. 

It is allowed by all continental writers of celebrity, that British practi- 
tioners have the credit of having been the first to point out the benefit of 
the non-mercurial treatment, in many cases where mercury was sup- 
posed to be necessary. Matthias deserved great praise for the discrimi- 
nation and judgment he evinced in distinguishing the effects of mercury 
acting injuriously on the constitution, from the effects of the venereal 
poison. 

Mr. Carmichael, of Dublin, was, however, the first who materially 



278 CLINICAL MEDICINE. 

improved this important practical branch of our profession, and taught, 
in a clear and scientific manner, when mercury ought or ought not to be 
exhibited. Mr. Green, of Bristol, has published, in the second volume 
of the Transactions of the Provincial, Medical, and Surgical Association, 
an excellent resume of the history and progress of opinion on the non- 
mercurial treatment, and has added many interesting cases observed by 
himself. From what he has seen and read he draws the following infer- 
ences : that every form and stage of venereal (except iritis) can .be com- 
pletely and better treated without mercury than with it ; that in some 
cases, mercury not only fails altogether to cure, but aggravates the disease, 
and therefore is not a specific ; and what have been considered as some 
of the worst secondary causes of syphilis, result from mercury itself, from 
the very means used to cure the disease. Dr. Thompson, of Edinburgh, 
zealously advocates the non-mercurial treatment, and supports his views 
by 400 cases treated without mercury. 

Mr. Green thinks Mr. Abernethy's test between true syphilis and 
pseudo-syphilis (namely, that the former requires mercury for its cure) 
erroneous. 

Mr. Rose, surgeon to the Guards, says he succeeded in curing all ulcers 
on the parts of generation, with the constitutional symptoms to which they 
give rise, without mercury. He treated 120 cases without any unfavour- 
able result. — Med. Chir. Trans, vol. viii. 

Mr. Guthrie treated nearly 100 cases of primary sores without mer- 
cury ; and thinks it an established fact, that every kind of ulcer on the 
genitals is curable without mercury — thinks, in some cases, a gentle course 
will expedite the cure, but does not consider it a specific for the venereal. 

Dr. Thompson remarks that in his cases treated without mercury, 
there were not any of those deep and foul ulcers of the skin, of the 
throat, of the mouth and nose, or the painful affections of the bones, 
which are stated by every writer on syphilis, as the general products of 
that disease. 

Dr. Hennen treated 105 cases of primary sores without mercury ; 
secondary symptoms followed in 11 cases: all were cured without mer- 
cury, except one obstinate and anomalous case. 

Report from the Army Medical Department, from December, 1816, to 
December, 1818. — There appear to have been treated, for primary venereal 
ulcerations on the penis (including not only the more simple cases, but 
also a regular proportion of those with the most marked characters of 
syphilitic chancre, as described by Hunter), 1940 cases ; that, of these 
1940 cases, 96 have had secondary symptoms of different sorts; of these 
96 cases of secondary affections, mercury was had recourse to in 12, for 
various reasons, as stated in the report. In the 1940 cases of primary 
symptoms, mercury was used in 65, for reasons also assigned. If we 
deduct the 65 and 12 cases in which mercury was used, from 1940, 1863 
cases remain completely cured without mercury. The average time 
required for the cure of primary symptoms without mercury, when bubo 
did not exist, has been 21 days, with bubo, 45. Average period for 
cure of secondary symptoms, without mercury, has been from 28 to 45 
days. In the same period, 2827 cases of primary symptoms were treated 
with mercury ; secondary symptoms occurred in 51 of them. The ave- 
rage period for cure of primary symptoms without bubo, was 33 days — 
with bubo, 50 days ; and for the cure of secondary symptoms, 45 days. 



SYPHILIS. 279 

Mr. Green treated 100 cases without a particle of mercury, either 
internally or externally. The primary sores were treated with sedativ T e 
and astringent lotions, or simple ointment ; all these sores possessed 
some of the characters of the true Hunterian chancre : from 14 to 30 
days was the time in which they were generally healed. One case of 
chancre resisted all applications for four months, till the person was 
removed to the sea-side, where it was healed in three weeks. Of these 
100 cases, buboes supervened in 16 : of these, 6 only suppurated. Con- 
stitutional affections, of one kind or another, followed in 9 cases ; these 
were, cutaneous eruptions, papular in 3, pustular in 2, vesicular in 1, 
vesicular and scaly in 2. These eruptions, at their commencement, were 
generally accompanied by pains in the limbs, and more or less fever. 
One of the cases of pustules closely resembled small-pox — has generally 
seen this particular form occur in persons of strong constitution. The 
vesicular and scaly eruptions occurred in delicate persons, and were very 
obstinate ; sore throat occurred in 4 cases ; in 3 conjoined with eruptions. 
Periostitis occurred in 2 cases, which yielded to counter-irritation. There 
was not one case of iritis. 

In 154 cases, treated by Dr. Thompson, without mercury, iritis fol- 
lowed in 1. In 417 cases, similarly treated by Doctor Hennen, iritis 
occurred only in 2. 

Mr. Green thinks that the use of mercury in primary symptoms, should 
be given up altogether ; but that in some cases of secondary it may be of 
use. From a comparison of facts, primary sores are sooner cured where 
mercury is not given. As far as the Army Medical Reports go, secon- 
dary symptoms followed more frequently where mercury had not been 
given, but they were not so severe as those which occurred after mercury 
had been given. The cases, in which he thinks mercury of use, are those 
in which the symptoms get into an indolent condition, and become a 
chronic disease. The superficial ulceration of the throat, which he con- 
siders truly syphilitic, frequently becomes changed by mercury into the 
deep excavasated ulcers of the tonsil. 

There can be no doubt, gentlemen, that mercury may be given to a 
person previously healthy, in such a manner as gradually to undermine 
the constitution and destroy health ; of this the workmen employed in 
quicksilver mines afford a melancholy example : and it is a striking and 
remarkable fact, that the mercurial cachexy thus produced, resembles in 
many respects the venereal. Emaciation, night-sweats, pains in the 
bones, nodes, and osseous caries, cutaneous eruptions and ulcers, redness 
and ulceration of the throat, loss of appetite and debility, are common to 
both. It is quite certain that these cachexies, when pure and unmixed, 
may, by an experienced examiner, be distinguished from each other with 
facility ; but the case is widely different when they coexist in the same 
constitution, each modifying and deteriorating the other. These two 
cachexies, combined in the same individual, occasion, according to the 
predominance of either, and the simultaneous and sinister presence of a 
weak, scrofulous, or scorbutic habit, those endless varieties of deplorable 
suffering, which we are so often called on to witness in cases, injudi- 
ciously, ignorantly, or negligently treated. I must refer you to authors 
for a more detailed and accurate account of the ill effects of mercury. 
Dr. Hennen has written with great clearness on this subject : he con- 
cludes by remarking, " but the most troublesome of all its effects, is the 




280 CLINICAL MEDICINE. 

phagedenic ulceration, which it often induces both in chancres and open 
buboes ; and the disposition to fresh ulcerations of a spreading and in- 
tractable character, which it gives rise to in parts where the skin had not 
been previously broken ; in the throat most severe ulcerations are excited 
by it, erosions of the gums and palate are produced ; and the papulae and 
other eruptions of the skin, which so often appear as a secondary form of 
the disease, are frequently exasperated into open ulcerations. I have not 
seen a single case of ulceration succeeding to a cutaneous eruption, in the 
military hospital, since the non-mercurial treatment has been adopted, 
except where mercury had been long and irregularly tried." 

The example set by British surgeons was soon extensively followed on 
the Continent, and many reports of the success of the non-mercurial treat- 
ment were published in France ; several of these have appeared in the 
English periodicals ; and some important documents of this nature have 
been lately cited by Mr. Carmichael, in a paper published in the 12th 
volume of the Dublin Medical Journal. As you can all refer without 
difficulty to French publications, I shall not detain you by quoting their 
contents, but shall at once proceed to submit to your consideration a 
translation of certain German writings, which contain important data con- 
nected with our subject, but which are not easily procurable, and cannot 
be understood without a very accurate knowledge of the German lan- 
guage and German pharmacy. 

To the first document I attach great value, having myself witnessed 
the progress of the treatment in the splendid and admirably-arranged hos- 
pital at Hamburgh, under the care of that able surgeon, Dr. Fricke, whose 
assistant, Dr. Giinther, took all the cases, and afterwards tabulated the 
results. Of course I cannot do more than present to you the general plan 
of treatment adopted, and the general conclusions arrived at. In the 
work itself numerous examples are given of each variety of primary and 
secondary affection, and the details of the treatment are accurate and full. 
As the non-mercurial plan excited much interest among German physi- 
cians, its details were watched with the most scrupulous accuracy, both 
by the medical men of Hamburgh, and by many who came from different 
parts of Germany to witness the progress of so important an experiment. 
That the details and results have been given, by Drs. Fricke and Giin- 
ther, with the strictest fidelity, I know, both from what I myself observed, 
and from what I heard from Dr. Oppenheim and others. 

I shall, in the first place then, lay before you copious extracts from Dr. 
Fricke's work, and afterwards communicate information I have recently 
obtained from this eminent surgeon, on this subject. 

After I have laid before you the later German authorities in favour of 
the non-mercurial treatment, I shall proceed to speak of those who bear 
testimony against it. 

From Fricke's Annals of the Surgical Department of the General Hospital, 

Hamburgh. 

Treatment of Syphilis, during the years 1824, 1825, 1826, and 1827. By Dr. Gunther, 

Assistant Surgeon. 

" The treatment of syphilis in our hospital may be divided into two 
periods. During the first, mercury was employed as the chief remedy ; 
during the second, the disease was treated after the non-mercurial plan. 
The former comprises, with males, a space of eighteen months and a half 



SYPHILIS. 281 

(from January, 1824, to July, 1825) ; with females, of twenty-two months 
(from January, 1824, to October, 1825). The latter includes, with males, 
a period of two years and five and a half months ; with females, of two 
years and somewhat more than two months." 

FIRST PERIOD. 
Treatment of Syphilis with Mercury. 

" I shall now communicate the principal facts and results of this mode 
of treatment, as the profession can have no particular interest in the more 
minute details, which can be useful only in the way of comparison. The 
forms of disease observed during the first period, may be seen in the an- 
nexed tables. On looking over them a considerable difference will be 
seen between them and those of the second period: syphilis having exhi- 
bited itself in a much more malignant form in the first period. Nocturnal 
pains, caries of the nasal, palatine, and other bones, obstinate and cuta- 
neous eruption, general lues, syphilitic cachexy, &c, were among the or- 
dinary phenomena; while in the second period they were of rare occur- 
rence, and observed only in those who had been subjected to long and in- 
jurious courses of mercury. 

"If we compare the forms of disease occurring in the same individual, 
at different times, before and during the first period, we shall not unfre- 
quently perceive a certain gradation from a favourable to an unfavourable 
constitution of disease; that which commenced with superficial ulcers of 
the genital organs subsequently appeared as bubo, then as ulceration of 
the throat, next as an extensive cutaneous eruption, which often gave rise 
to ulcerations, then harassed the patient with nocturnal pains, nodes, 
caries of the bones of the face and loss of the hair until it terminated in 
syphilitic cachexy, general and incurable lues, consumption, emaciation, 
and dropsy. 

" The mode of treatment employed during this first period was various, 
and regulated by the peculiarities of each individual case. No undue pre- 
dilection was shown for any particular preparation of mercury. The solu- 
ble mercury of Hahnemann was chiefly employed, in doses of a grain twice 
a-day ; in a great many cases calomel was used in the same proportions. 
Corrosive sublimate was given in solution (gr. iij. ad 5VJ.) generally in 
combination with a little opium or with the decoction of columbo ; a table- 
spoonful three times a-day. In obstinate cases calomel and corrosive sub- 
limate were administered alternately, in the form and doses already men- 
tioned ; and this mode of administration was looked upon as very power- 
ful and efficient. On one occasion calomel was given in large doses (ten 
grains) ; and 33 cases were treated with mercurial frictions, after the man- 
ner recommended by Rust. The latter, which were employed in the cases 
of 13 females (in some individuals twice), were had recourse to only in 
obstinate and extensive forms of the disease. When syphilis was attended 
with distinct inflammatory symptoms the antiphlogistic treatment was put 
into operation before mercury was administered. 

"With respect to the duration of treatment a remarkable difference will 
be perceived on inspecting the tables of both periods. I have taken an 
average of the number of days spent in hospital, as well by patients labour- 
ing under peculiar forms of syphilis, as by the general class, and added it 
to the tables. The relative proportion of this cannot be always easily 



282 CLINICAL MEDICINE. 

stated, for no general law can be deduced from a few cases ; but, on com- 
parison, a difference in favour of the non-mercurial plan of treatment is 
readily perceived. 

" With regard to the certainty of cure, so far as the mercurial treatment 
is concerned, we must say, with many of our unprejudiced colleagues, that 
we are convinced by bitter experience that syphilis very often returned, 
in the secondary form, after the most cautious use of mercury, the most 
careful selection of the preparation, the strictest attention to diet, and a 
proper observation of precautionary measures. Of 573 patients, treated 
during the first period, 165 (i: e. nearly one-third) were attacked with 
secondary symptoms. All these were treated with mercury for the pri- 
mary symptoms, although it is to be observed, the smallest portion of them 
had been under our care. Of those patients treated during the second 
period, who were attacked with secondary syphilis, by far the greater por- 
tion had, at an earlier period and before admission, or while in hospital, 
used mercury for the cure of the disease. Many patients, in whom the 
disease was supposed to have been eradicated, came back (particularly 
after the use of mercurial frictions) with caries of the bones of the face ; 
some of these were afterwards cured without mercury, others are still 
under treatment. 

" On examining the bodies of those who died while under treatment, 
particularly during the use of mercurial frictions, and while the mouth was 
affected, we did not find the parotid, sublingual, or pancreatic glands en- 
larged ; they were, however, harder than usual, and, when slit open, had 
in a remarkable degree the unpleasant odour attendant on salivation. In 
one case the submaxillary glands were enlarged, but, with the exception 
of some slight induration, otherwise unchanged. In the case of a young 
woman, who had frequently used mercury, and who died twenty-two days 
after a protracted course of frictions — on boiling some portions of the thigh- 
bone (the head, neck, and trochanter) and of the tibia for an hour in water, 
we found somewhat more than half a drachm of mercury. In two or three 
similar cases, where so much mercury had not been employed, we could 
not detect any." 

SECOND PERIOD. 
Treatment of Syphilis without Mercury. 

u When this mode of treatment was introduced into our hospital by 
Dr. Fricke, he at first submitted only a small number of patients to it, 
and selected chiefly those whose future prospects depended on their being 
cured in the speediest possible way. Having afterwards discovered, con- 
trary to his expectation, that the disease was cured more rapidly in this 
way, and relapses much fewer and slighter, it was extended to all cases, 
with such modification as experience suggested. 

" At this present time (February, 1828), after a trial of two years and 
a half, and the successful treatment of more than a thousand patients, the 
results of this treatment have proved so favourable, that there appears no 
reason for lightly abandoning it, or returning to the former plan of treat- 
ment. As already stated, patients are cured in a much shorter time than 
before, and leave the hospital with much healthier looks. All the un- 
pleasant phenomena attendant on salivation no longer harass them. 
Formerly, notwithstanding the greatest attention and cleanliness, it was 



SYPHILIS. 283 

impossible to remove the foul smell from the venereal wards, or to keep 
the rooms or beds clean ; the air was tainted with the offensive odour of 
salivation and syphilitic caries; and filth was the order of the day in all 
the wards occupied by patients under full salivation. At present there is 
not a trace of this air in a ward containing constantly 60, 70 and some- 
times 100 patients ; and the venereal department of the hospital rivals 
the other divisions in purity of air and cleanliness. Syphilis, too, seems 
to become gradually more simple ; at least it never appears in the same 
malignant form as before, where little or no mercury has been used. As 
every medical man is allowed to visit the hospital, anyone may convince 
himself of the truth of these statements. 

"From the strict surveillance over prostitutes observed by the police, 
the attention and experience of the surgeons appointed by the govern- 
ment to inspect them, and from the circumstance that such females come 
to our hospital for the relief of all diseases under which they may happen 
to labour, we are enabled to keep a strict control over their diseases. 
Those who live in the town, constituting three-fourths of them, under the 
jurisdiction of Hamburgh, and those who live in the suburb named Ham- 
burgerbery, are examined twice a-week by two government surgeons. 
Every female is obliged, each time, to bring a book, in which her state of 
health is entered. Those who are found diseased are immediately sent to 
the hospital. Unfortunately, we cannot exercise the same control over 
males, and with the same accuracy and precision. A large portion of the 
males under our care leave Hamburgh, and many of them, when they get 
fresh infection or secondary symptoms, apply to other physicians of this 
city, and are generally treated with mercury. Hence, of course, in such 
cases, the accuracy of the result is disturbed and rendered uncertain. 
Many who are cured and remain well, do not keep the promise which is 
exacted from all who are dismissed cured, namely, to let us see them 
again. Some, in fine, lose patience, and leave the hospital before their 
cure is entirely completed. This, however, has not occurred for the last 
half-year. All these circumstances combined render it extremely difficult 
to ascertain the truth in each individual case. There remains, however, 
a number of male patients whom we keep constantly under observation. 

GENERAL TREATMENT. 

" Four conditions we endeavour to fulfil, viz. cleanliness, rest, a strict 
diet, and (in a therapeutic point of view) an antiphlogistic plan of treat- 
ment. 

" Cleanliness is of the greatest importance towards a speedy and suc- 
cessful termination to the cure ; several patients were cured by the use of 
warm baths and ablutions. On the other hand, a neglect of this precau- 
tion has been the cause either of the origin or of the deterioration of many 
forms of disease. On entering the hospital, all syphilitic patients, unless 
perfectly clean, are put into a warm bath. With women this is seldom 
requisite, with men almost always. The diseased parts, and those in the 
vicinity, are frequently washed with warm water. This operation requires 
to be looked after more carefully in men than in women, the latter being 
naturally more cleanly. Again, places on which ulcers, condylomata and 
exanthemata, are seated, the glans and prepuce in gonorrhoea, and all 
carious bones, are cleaned of pus, mucus, and dirt, by frequently washing, 
sprinkling, rinsing, and syringing with warm water. Pus is never allowed 



284 CLINICAL MEDICINE. 

to collect on ulcers, or on the prepuce or glans in gonorrhoea. A most 
important rule is, to prevent excoriations, chancres, and condylomata, from 
coming in contact with the healthy mucous surface or skin ; as for instance, 
in the angles between the carunculae myrtiformes and nymphee, between 
the labia, between the testicle and the upper part of the thigh, &c. as in 
course of time not only the sound parts become excoriated or ulcerated, 
but also the disease protracted and often very much exasperated. We 
also take care to prevent excoriation, exanthemata, and condylomata, 
from forming in the angles and folds of the genital organs from the matter 
of gonorrhoea or ulcers. To accomplish this end we put pieces of linen 
or charpie, wet with spring water, saturnine lotion, or black wash, into 
each fold or angle, changing them three or four times a-day, and some- 
times oftener, according to circumstances. This attention to cleanliness 
is also of the greatest importance after the cure is finished, because the 
cicatrices are apt to become raw and turn into excoriations or ulcers when 
neglected. This has frequently occurred in patients discharged cured, 
who on being admitted a second time, have been again cured by strict 
attention to cleanliness. 

" Rest is necessary, particularly during the first period, and where the 
disease exhibits an inflammatory character. Hence, all patients, on ad- 
mission, are confined to bed. In women this regulation was enforced 
throughout : on the other hand, males were generally permitted, and with 
advantage, to walk about during the later period, where a chancre or 
opened bubo had healed up to a certain point and then become stationary. 
The reason of this difference between the treatment of males and females 
was partly this, because in the latter, the diseased parts are not so easily 
protected from contact with the sound skin or mucous membrane, from 
friction, or from becoming wet with pus, mucus, &c. Pregnant women 
were permitted to walk about a little. 

" With regard to diet, each patient at first received every day four 
ounces of bread, three pints of gruel, and six spoonfuls of vegetables, at 
noon ; the latter varying according to the season of the year. They were 
not allowed to drink beer, brandy, or w T ater, their common drink being 
thin gruel. As soon as the characteristic appearance of the ulcers began 
to vanish, or an improvement took place, the diet was gradually made 
more nutritious, according to the state of the constitution and the wants 
of the patient ; and when matters went on favourably in this way, meat 
was allowed. We have departed from this rule in the case of very weak 
individuals, and persons who had been debilitated by mercurial courses, 
allowing these a nutritious diet from the commencement. In the case of 
females, who seldom remained in hospital longer than three or four weeks 
(some not more than fourteen days), and who require less food than 
males, the first kind of diet was generally continued until the termination 
of the cure ; in males it was usually changed a fortnight or three weeks 
after the character of the disease began to improve. The appearance of 
those who were dismissed after a long stay in hospital, was that of men 
in perfect health, and (where the strict diet had not been continued too 
long) not at all deficient in bodily strength. 

" The therapeutic measures employed were by no means complicated, 
and have been latterly rendered more simple. At first every person who 
could bear it, whether male or female, was blooded to eight, ten, or twelve 
ounces. Experience, however, has taught us that in most cases general 



SYPHILIS. 285 

bleeding may be dispensed with, and thai the end in view maybe accom- 
plished in as short a time, and with equal success, by observing the rules 
already laid down. Hence venesection is at present confined to cases of 
plethoric habit or high local inflammation, and consequently not very 
often employed. In some peculiar forms of disease leeches were used. 
In cases of secondary syphilis, particularly where the disease came on 
after the non-mercurial treatment, venesection was occasionally employed. 
The treatment was generally commenced with the following medicine : — 

" R. Sulph. Magnesias, ^iss. ; Aquae Fceniculi, ^viij. M. 

" Of this a tablespoonful was administered three times a-day, or oftener, 
so as at first to produce several stools, and afterwards one during the 
course of the day. Occasionally a collection of bile in the prima? viae, 
which sometimes occurred under the continued use of this mixture, re- 
quired the administration of an emetic. The mixture was given to pregnant 
women, merely in such doses as to keep the bowels regular. In secondary 
syphilis the decoction of the woods and nitric acid were also employed. 
Alter a long and copious use of the laxative mixture, aphthous excoria- 
tions of a circular shape, and from three to four lines in diameter, were 
sometimes observed on the inside of the lower lip and mucous membrane 
of the cheeks. These had a ilocculent appearance, were painful, and 
surrounded with slightly swollen edges. Frequently they were combined 
with small tallow-like sloughs of the mucous membrane at the angles of 
the mouth, frequently with raw surfaces. Persons of a scorbutic or scro- 
fulous diathesis were very subject to them. They were often very obsti- 
nate, and required the use of acid or astringent gargles, touching with 
solutions of caustic, and the omission of the laxative mixture. 

" In a few cases we have seen a more than usually copious flow of 
saliva after the use of nitric acid, frequently a slight increase in the cuta- 
neous transpiration, or an increased secretion of saliva, after decoction of 
the woods had been employed for some time. Nitric acid was exhibited 
in the following form : — 

'« R. Acidi Nitrici, ^ss. ; Syrupi Simplicis, 3J. ; Decoct. Averue, 3 xij. If. 

Of this mixture a tablespoonful was given every second hour, and some- 
times every hour. From eight to twelve ounces of the decoction of the 
woods were administered every day. Saponaceous baths were ordered 
for the sake of cleanliness, as also in some forms of eruption ; in others, 
baths containing muriate of soda, or mineral acids, or corrosive subli- 
mate, or (in cases of pains in the bones) caustic potass. Many kinds of 
lotions were also used for moistening the charpie.and linen used in 
dressing the sores." 



LECTURE XXVI. 



In continuation of the subject spoken of at our last meeting, I shall re- 
sume the translation of some of the most important parts of Dr. Fricke's 



286 CLINICAL MEDICINE. 

work. The great length of the extracts I am about to lay before yoa 
sufficiently attests the value I attach to that work, and I have no doubt 
that you will concur in the favourable opinion I have formed of the merits 
of this celebrated surgeon. 

Let us now return to Fricke's treatise. 



M CHANCRES ON THE GENITAL ORGANS. 

" Of chancres (differing from excoriations by an excavated base, and 
corroded edges), we have observed seven different species, distinguished 
from each other either by their appearance, their degree of intensity and 
extent, or by the mode of treatment they require. 

" 1st Species. — Chancres with a clean, and in general, copper-coloured 
base ; the base deeper than the edges, the edges sharply cut, but not 
raised above the epidermis ; diameter from one to four, and six lines. 
They constitute the transition from the third species of excoriations. 

fc< 2d Species. — Chancres with an ash-coloured, and usually soft base ; 
the base deeper than the edges, the edges cut, but not raised above the 
epidermis ; the diameter from one line to one or two inches. 

" 3d Species. — Chancres with an ash-coloured, and in general, hard 
base ; the base deeper than the edges, the edges sharply cut, indented, 
raised above the epidermis, everted, often of a dark red colour, and 
inflamed ; diameter from one to four or five lines. (The Hunterian 
chancre.) 

" 4th Species. — Chancres with a depressed base covered with an adhe- 
sive, viscid, greyish-green matter. The base is irregular, in many places 
deeper, in others shallower. The edges cut, raised above the epidermis, 
everted, often intermixed with livid black (gangrenous) spots; the cir- 
cumference inflamed : diameter from three or four lines to an inch or two. 
They are always in connection with great destruction of the neighbouring 
parts. (Carmichael's phagedenic chancre.) 

" bth Species. — The base scarcely deeper than the epidermis, but much 
deeper than the edge ; the edge raised above the base and the epidermis, 
not sharply cut, rounded off towards the base, which is surrounded like a 
rampart. In general the base was not ash-coloured, but for the most part 
of a pale reddish colour, without any appearance of commencing granu- 
lations. These chancres were usually attended with a copious discharge, 
and very apt to produce excoriations of the first species on the parts in 
their immediate vicinity. With the edge they generally measured from 
four to six lines in diameter. They were frequently covered with a scab. 
(Transition to the semiglobular condyloma.) 

" 6th Species. — The base raised above the epidermis, of a spongy and 
in general bluish-red appearance ; no distinctly formed edges ; the sur- 
rounding skin not inflamed. 

" 1th Species. — Hemorrhoidal chancres. Raw surfaces formed on hard 
hemorrhoidal tumours, with a whitish but not ash-coloured base. The 
tumours themselves were flat, compressed, and full of fissures. The 
tumours often exhibited excavations with an ash-coloured base and cor- 
roded edges. These chancres were attended with a copious discharge, 
and were extremely painful. (Transition to the quadrangular condy- 
loma.) 

" We have frequently observed a transition from chancres of the first 



SYPHILIS. 287 

species to the second, third, and fourth, produced by neglect, improper 
diet, constant bodily labour, and want of attention to cleanliness. We 
very rarely observed ulcers of the fourth species among females, except 
in a few cases of maid-servants who had venereal ulcers for a long time 
without having any thing done for them. In men we generally observed 
them behind the glans, in the angle between it and the prepuce. The 
transition from the first to the other species was sometimes very slow, 
sometimes exceedingly rapid. Artificial ulcers, formed three times with 
corrosive sublimate on females, and twice with lapis infernalis on males, 
resembled chancres of the third species. 

" With respect to the origin of chancres, those of the four first species 
were formed in a threefold manner. In the first place, the well-known 
vesicle, filled with clear pale lymph, formed on the sound or inflamed 
skin. The circumference became inflamed, the lymph changed into puru- 
lent matter, the vesicle burst, and gave rise to a chancre of the first spe- 
cies, which after the lapse of twenty-four or forty-eight hours became 
converted into a chancre of the second species, and under the operation 
of the circumstances already mentioned, into one of the third or fourth 
species. We observed this mode of origin very often in men, particu- 
larly in chancres of the glans, but very seldom in women. In the second 
place, from excoriations particularly of the third kind, chancres of the first 
species formed ; these either remained in this state, or changed into one 
of the other three species. The change was generally very slow. Some- 
times, however, a slight excoriation of the third kind, from neglect on the 
part of the patient, before admission into hospital, became converted in 
the space of three or four days into the phagedenic ulcer of Mr. Carmi- 
chael. This mode of origin we have frequently observed in both sexes, 
particularly in chancres behind the glans. In the third place, chancres 
formed in the mucous follicles of the inside of the nymphae, the openings 
of which are very distinct, particularly in young females. These small 
follicles inflamed, suppurated, and, when the openings closed, and the 
pus went deeper, formed abscesses. When the matter was discharged 
externally (a much more frequent occurrence) either by the pus escaping 
through the natural opening, or by the breaking of the abscess, chancres 
were formed most commonly of the second species. In this manner fistu- 
lous and chancrous ulcers formed, which, on account of their minute size 
and concealed situation, repeatedly escaped an unpractised eye. We 
frequently found ulcers on one and the same spot in prostitutes, and this 
spot proved to be the seat of a fistulous follicle : when this was destroyed 
with caustic, the tendency to have chancres on one and the same spot 
ceased. These fistulous ulcers looked like a small, thin, dark red follicle, 
darker than the surrounding healthy membrane, with a small opening in 
the centre, permitting the escape of a small quantity o( pus on pressure, 
and with their edges inverted. This origin of chancres was extremely 
frequent among females ; on the other hand, we have seen only a few 
examples of it among males, on the inner lamella of the prepuce. These 
mucous follicles often closed, and seemed to be healed up, but always 
broke out again in a short time. 

" Chancres of the fifth species, in cases where we had an opportunity 
of observing their mode of origin, formed from semiglobular condylomata, 
which having first secreted a fluid, and afterwards been exposed to fric- 
tion, gave rise to excoriations. 



288 CLINICAL MEDICINE. 

<c On the origin of the six species, we had no opportunity of making any 
observations. Hemorrhoidal chancres formed where hemorrhoidal tumours 
were exposed to friction, and to the contact of leucorrhceal or gonorrheal 
matter. 

" Chancres of the first four species in women were most commonly situ- 
ated on the fossa navicularis, the remains of the hymen, the internal wall 
of the nymphae, in the angles between the nymphse and carunculse myrti- 
formes, and on the anterior edge of the labia; less frequently in the ure- 
thra, and around it, in the angles between the labia and nymphse, on the 
outer surface of the nymphse, on the frsenum itself; more rarely still in the 
space between the urethra and vagina, or between the urethra and the 
clitoris, on the outer surface of the labia, or in the vagina. In the latter 
case, we always observed a smaller or greater protrusion of the walls of 
the vagina, on which a chancre of small size was discovered. Chancres 
on the anus (which were observed only in a few cases) were the result of 
unnatural coition. 

" In men chancres were situated on the glans, behind the corona glandis, 
on the fraenuni, on the inner surface of the prepuce, in the urethra, and at 
the junction of the external with the internal lamella of the prepuce-; less 
frequently on the outer lamella of the prepuce, on the dorsum or under 
surface of the penis, and on the scrotum ; still more rarely, on the peri- 
neum, anus, pubes, and inside of the thigh; the latter from contact with 
the organs of generation. 

" Chancres of the fifth species were situated in women on the labia, the 
outer surface of the nymphee, the inner and upper part of the thigh, and 
frequently on the perinseum; in men on scrotum and penis, particularly 
the under surface, the perinseum, and the upper and inner part of the thigh. 
All ulcers occurring on the scrotum exhibited this form. 

" Spongy chancres (sixth species) were seated on the inner lamella of 
the prepuce, and sometimes in the angle between the prepuce and glans. 

" Hemorrhoidal chancres of course were naturally seated on the circumfe- 
rence of the anus. 

" With respect to the prognosis of chancres, we were always able to 
make it invariably good. None of the different species extended to any 
remarkable degree either in depth or circumference, when once submitted 
to treatment. Even phagedenic chancres, which had in many cases com- 
mitted great ravages before the patients' admission, healed in such a man- 
ner that a considerable portion of the devastation was repaired by healthy 
granulations. In one case only, a large portion of the glans which had 
been lost before admission was never reproduced. All the ulcers healed, 
and all the cicatrices were firm and good. With respect to each indivi- 
dual species the following was our experience. 

" 1. On the whole, chancres of the first species healed in the shortest 
space of time. Those of the second and third healed more slowly, those 
of the fourth most slowly. The spongy chancre (6th species) occupied 
an intermediate rank; the condylomatus (5th species) and the hemor- 
rhoidal chancre (7th species) were often extremely obstinate. 

" 2. Hunterian chancres so small as to measure only a line in diameter, 
were (proportionally to their small size) extremely slow in healing. 

"3. Chancres around the orifice of the prepuce, on the scrotum and pe- 
rineum, were generally slow in healing; those behind the corona glandis, 
on the glans and on the labia, required for the most part but a short time 



SYPHILIS. 289 

for their cure. Ulcers on the fraenum in males were very slow in cicatriz- 
ing. 

"4. Chancres produced and kept up by a raucous follicle, usually did 
not heal until the follicle was destroyed. 

" 5. Chancres healed in the best and speediest manner with patients 
who had used nothing for the disease before admission: they were most 
obstinate in patients of a scorbutic, scrofulous, or phthisical habit. 

"6. Chancres with a brownish base were generally tedious. 

"7. Some chancres proved remarkably obstinate, without any sufficient 
cause that we could discover. 

" 8. Chancres made by art required the same time for their cure as 
Hunterian chancres of similar size. 

" With respect to treatment, the following details exhibit the course 
pursued : — 

" In all cases where chancres were seated in the folds of the organs of 
generation, as, for instance, between the labia and nymphae, the latter 
and the carunculaa rayrtiforraes, &c, the lips were separated, the angles 
cleared, frequently washed, and covered with charpie dipt in water or 
saturnine lotion, and the dressing renewed two or three times a-day. If 
the ulcer suppurated freely, the dressing was used oftener. If there was 
no advance in the healing process, the lotions were changed, and lime 
water, aqua phagedaenica nigra, a solution of four grains of sulphate of 
zinc in eight ounces of water, decoction of elm bark, a scruple of the 
oxide of zinc in eight ounces of saturnine lotion, were then employed. 
Or recourse was had to ointments, which were used chiefly in cases where 
the chancres had become very small, and suppurated sparingly. Zinc 
ointment, or the following, were in general preferred : — 

"R. Unguenti Zinci, 5ss. 
Balsam. Peruviani, ^j. 
Pulv. Lapidis Infernalis, 9j. 
M. Signetur — the black ointment. 

" This was found extremely serviceable in cases where the ulcer was 
healed up to a certain point, but would not cicatrize. The ointment was 
allowed to remain unchanged for two or three days, until it was thrown 
off by pus, or with a scab. If the new skin exhibited any roughness or 
chafing, so as to threaten to break, and become raw again, we were in 
the habit of smearing it w T ith zinc ointment for several days succes- 
sively. 

" In case of ulcers with a copper-coloured base, marsh-mallow oint- 
ment did more service than any thing else. Often we were obliged to 
try many ointments before we could hit on a good one. 

" When the healing process was advancing, pencilling the edges of the 
sore with a weak solution of lapis infernalis, greatly promoted diminution 
of the chancre. 

" Condylomatous (5th species) w T ere treated in the commencement, 
partly by frequent ablution with soap and warm water, partly by applying 
pledgets dipped in saturnine lotion. After this they became drier, the 
central portion of the base became elevated, and the edges began to 
approximate and unite. The semiglobular elevations also diminished, 
but they w T ere rarely removed by these means alone. They were then 
pencilled over with Plenk's liniment, according to the following recipe : — 
20 



290 CLINICAL MEDICINE. 

" R. Mercur. Sublimat. Corrosiv. Oamphorse, aa gr. xij. 
Alum. Crud., Sacch. Saturni, aa, ^j. 
Misce, terendo et adde Acet. Concentr. gij. 
Solution! vitro immissaea adde ^Ether. Suiphur. gj. 
Conquassa. Signetur " Plenk's Liniment." 

u When the elevations had been pencilled for a few days with the white 
sediment of this liniment they began to exfoliate, shrink and diminish in 
size. If they resisted this application, they were touched for several days 
in succession with fuming nitric acid, or cut off with the scissors. This 
kind of ulcer, however, was very apt to return again where attention to 
cleanliness was omitted. 

" The spongy ulcer (6th species) was covered with charpie dipt in the 
following lotion : — 

" R. Aluminis Crudi, Cupri Sulphatis, aa sjss. 
AqusB fontanse, ^ xij. M. 
Signetur " the green lotion." 

" If this happened to be too strong, the decoction of elm bark was sub- 
stituted. The ulcers were treated in this way until the base became 
reduced to the level of the skin, a small palish blue film surrounded it, 
and the raw surface in this way diminished in size. 

"Hemorrhoidal chancres were also treated with saturnine lotion ; in 
many instances hard hemorrhoidal tumours were cut off with the scissors. 

u On many occasions we have attempted to destroy with caustic the 
small vesicles from which chancres often arise, in order to prevent the 
formation of chancres ; but a much larger sore was produced in this way, 
than if they had been allowed to run their course as usual. Sometimes, 
however, we succeeded in preventing them from passing into chancres 
by smearing them with zinc ointment as soon as ever they were observed 
on the glans. Under this treatment they sometimes dried up without 
forming sores. 

u Cataplasms were very often employed ; under the following circum- 
stances they were very efficacious : — 1st. Where the edges of the sore 
were very hard, callous, and everted. 2d. Chancres would frequently 
heal up to the size of a millet-seed, and then become stationary, or even 
get worse, from the formation of excavations under the edges. In such 
cases we applied charpie dipped in decoction of elm bark over the ulcer, 
and over the latter a poultice. These measures in general answered our 
expectations. 3d. When the base was covered with a firm, dense, ash- 
coloured layer. 4th. Fistulous ulcers of the mucous follicles were often 
healed up completely by cataplasms. 5th. We also found them extremely 
serviceable in softening hard, callous, and chapped cicatrices. Finally, 
when cicatrices broke out afresh a few days after healing, we applied 
cataplasms either immediately over the raw surface itself, or previously 
touched with zinc ointment, black salve, or the lotions above mentioned. 

" We observed that the four first species of chancres were accustomed 
in healing to pass through the four stages already mentioned, in succes- 
sion. Often a phagedenic chancre after three or four, and sometimes 
after eight or ten days, began to change its character, the edges became 
softer, flatter, less elevated, and less everted, and the surrounding inflam- 
mation assumed a milder aspect. The ash-coloured layer which formed 
the base became thinner, the gangrenous parts were detached, the ine- 



SYPHILIS. 291 

qualities of the base disappeared, and new red and healthy granulations 
sprang up among the ash-coloured spots which formed the base. The 
edge then sank on one side (rarely at different spots simultaneously), the 
base became elevated in the same direction, suppuration went on healthily, 
and small but not well-defined patches of epidermis became visible on 
the surface of the ulcer. The remaining edges sank down in a similar 
way, the base became elevated, the small cicatrized points approximated, 
and the ulcer completely healed. 

A very large deep phagedenic ulcer, with or without phymosis, re- 
quired from four to six or eight weeks, and sometimes more, to heal. 

" ON THE PREDISPOSITION TO CHANCRES. 

" We have often been able to verify the observation, that many men, 
and young women especially, are extremely liable to venereal infection, 
and in particular to the formation of chancres. The following are the 
results of our experience on this point: — 

" 1. All young women not attentive to due cleanliness were very easily 
infected. We have seen this observation confirmed in numberless in- 
stances. From some brothels, young women labouring under syphilis, 
and particularly under chancre, were sent to us much more frequently 
than from others ; from the former the greater number of patients afTected 
with itch were admitted, and much less cleanliness was observed than in 
the others. 

" 2. Young women with very narrow vaginae were very readily at- 
tacked with excoriations of the nyraphaa, the carunculae myrtiformes, and 
fossa navicularis, which subsequently became chancres. Whenever we 
meet with this state we endeavour to dilate the vagina with bougies gra- 
dually and cautiously employed. 

" 3. The shorter the period elapsed since defloration, the more readily 
did chancres and excoriations form ; since prostitutes who had been a long 
time on the town were much seldomer infected. 

<c 4. Young women of scrofulous habit, or very delicate skin, were very 
apt to get chancres. 

" 5. But above all, those who had the mucous follicles of the vagina 
highly developed were peculiarly liable to the formation of chancres or 
abscesses. The mouths of these follicles, particularly in young women of 
full habit, may be seen very distinctly on the inner surface of the nyraphae. 
They are sometimes so large as to admit the end of a probe with ease. 
When inflamed, the parts around are of a darker colour, and the mouth 
of the follicle somewhat elevated. As we have already stated, they be- 
come very readily converted into abscesses, but more frequently into 
chancres. Sometimes, on dismissing a female patient, we have been able 
to determine beforehand the spot on which a chancre would be found on 
the next infection, viz., the situation of mucous follicle with a large open- 
ing. Hence we have often thought it necessary to make an incision through 
the follicle, and then burn it out completely with lapis infernalis ; after 
which, we never found a chancre to form on the same spot. 

11 CONDYLOMATA. 

" Condylomata, which are so rarely seen in this country (at least in 
proportion to the other forms of primary syphilis), constitute one of the 



292 CLINICAL MEDICINE. 

most common forms of the disease in Germany, and are looked upon as 
extremely obstinate, slow in healing, and very apt to return. Six differ- 
ent species have been observed by Dr. Fricke. 

" 1. Conical condylomata. — These resemble grains of peeled barley, 
of a whitish colour aggregated, and more commonly observed in females. 
Their situation was on the inside of the nymphee, between the nympha? 
and labia in the vagina, behind the corona glandis, and on the inside of 
the prepuce. They required excision and cauterization, and were very 
apt to return : they sometimes appeared spontaneously during the period 
of the catamenia. 

" 2. Scollop-shaped condylomata. — These sometimes resembled a cocks- 
comb in shape, sometimes they were more like a strawberry or a cauli- 
flower, but the original form was that of a scollop or cockscomb. They 
grew to the height of half or three-quarters of an inch in some instances. 
When small they were generally of a white colour, and covered with a 
whitish exudation. They were of a delicate texture, hollow, and when 
tied, appeared full of bright red blood. When cauterized superficially 
they increased in size, and became indurated on the surface ; they were 
in general aggregated, and occurred more frequently in men than in 
women. Their situation was for the most part the same as that of the 
foregoing. Sometimes they projected from the urethra and were occa- 
sionally found in the vagina. They required excision and full cauteriza- 
tion, but often disappeared of themselves, or under very simple treatment. 
They were treated with lapis infernalis, Plenk's liniment, calomel and 
powdered savine, a solution of corrosive sublimate (gr. i. ad §i.), and ex- 
cision. 

" 3. Polypoid condylomata. — These were fleshy, roundish, soft, and 
somewhat redder than the mucous membrane of the vagina. The base 
was as broad as the summit ; they were seldom observed, occurred only 
in females, and on the perineum between the labia and nymphae, and on 
the clitoris. When removed by excision, and cauterized, they seldom 
returned. 

"4. Urethral condylomata. — These were observed in females at the 
opening of the urethra, and differed but little from the polypoid condylo- 
mata. They were sometimes cured by excision and cauterization ; some- 
times they were so obstinate that it was found useless to apply any reme- 
dies. Several prostitutes were known to have them for a considerable 
time and follow their avocation without injury to others. 

"5. Semiglobular condylomata. — These were seated on the skin, with 
a broad surface, and varied from the size of a split pea to that of half a 
musket-ball. They were pale or whitish, covered with moisture, some- 
what excoriated, and became converted by neglect into condylomatous 
chancres. They were generally situated in the vicinity of, but not on, 
the mucous membrane of the organs of generation. They were ex- 
tremely infectious, and readily gave rise to similar condylomata or chan- 
cres on the parts with which they lay in contact. Their treatment was 
very simple ; cleanliness and isolation were the principal requisites. When 
reduced to certain size, by use of simple astringent washes, they were 
completely removed by caustic applications. 

"6. Quadrangular condylomata. — These were seldom observed, were 
more common among males than females, and were always situated round 
the anus. Their form was square or trapezoid, compressed on the surface, 



SYPHILIS. 293 

lying close together, and separated by fissures, from which a considerable 
quantity of moisture exuded. They were somewhat paler than the epi- 
dermis, and in some cases seemed to have owed their origin to old indu- 
rated hemorrhoids. They required more active treatment than the fore- 
going, and were slower in disappearing. 

" Condylomata of all kinds occurring in pregnant women were treated 
with caution, and excision or cauterization was seldom employed. 

"venereal sore throat. 

" (Chancres in the throat — Chanker im halse.) 

" Venereal sore throat appeared in the form of ulcers of the tonsils, the 
arches of the palate, the uvula, the soft palate, or the posterior wall of 
the pharynx. 

" With respect to their origin and course, ulcers of the tonsils exhibited 
the three following forms. 

" In the first form the tonsils swelled, acquired a deeper red colour, 
produced slight pain in swallowing, either at the commencement or sub- 
sequently, and gave a kind of nasal tone to the speech. The tonsils then 
increased in circumference and depth, and exhibited on the surface white 
purulent vesicles which burst, became gradually deeper and formed ulcers 
which at first had nothing characteristic, but by neglect, became greatly 
enlarged, and assumed an ash-coloured appearance; when the tonsils 
happened to be greatly enlarged and swollen, the base of the ulcer ap- 
peared hollow; the edges were sharp, corroded and everted. The base 
was often of a greenish colour and the circumference inflamed. In this 
way these ulcers would pass through the four first stages of ulcers on the 
genitals, with this exception, that they never became truly phagedenic. 
When the ulcers went on unchecked, they became larger, and involved 
the neighbouring parts (this, however, rarely occurred), or new ulcers 
formed in the vicinity, and coalesced with the latter. The healing pro- 
cess went on as in the case of ulcers of the genitals, with this exception, 
that it was often difficult to determine with precision whether the tonsillar 
ulcer was really healed or not, because the cicatrices looked deep and an- 
gular at first, or even for a considerable time, and were often covered 
with whitish streaks, which might be easily mistaken for ash-coloured 
ulcers. 

" Ulcers of this form appeared almost as frequently after the mercurial 
as the non-mercurial treatment, and were generally observed on men of 
robust habit. They healed slowly, and were very apt to return. 

"The second species of ulcers of the tonsils formed without tumefac- 
tion or inflammation. The first appearance was a broad patch of exco- 
riation, the base of which exhibited nothing like excavation, but on the 
contrary was often elevated. It was either not at all, or very slightly ash- 
coloured, the edges indistinctly cut. This excoriation extended over the 
whole tonsil, and had this peculiarity, that it very seldom affected the 
voice, and only in a very slight degree. Ulcers of this description were 
most common after the non-mercurial treatment. They were cured easily 
and rapidly, and often healed spontaneously. 

" In the third species of ulcer, the tonsils swelled greatly, but were 
neither inflamed, painful, nor altered in colour. Circular excavations 
formed, secreting a muco-purulent fluid, and of which it was impossible 



294 CLINICAL MEDICINE. 

to say with certainty, whether they were real ulcers or the mouths of the 
enlarged mucous follicles. These swellings affected deglutition, but did 
not in genera] interfere with speech ; they appeared most frequently after 
the mercurial treatment, did not get worse, and when they had attained 
to a certain height, generally resisted all applications, so as frequently to 
require excision. Enlargements of the tonsil, without any ulcer-like 
cavities were not unfrequently observed; these either formed . of them- 
selves, or remained after the healing of ulcers of the third species, and 
often required excision. 

" Ulcers of the arches of the palate and uvula were frequently observed. 
They were always ash-coloured, surrounded by an inflammatory border, 
interfered greatly with speech, and generally appeared after the mercurial 
treatment, but were not refractory to treatment. 

"Ulcers on the soft palate commenced in the form of vesicles situated 
on an inflamed base, containing, the first day, a transparent fluid, which 
became thicker on the third and fourth day, when the vesicle burst, and 
became converted into a Hunterian chancre. Frequently a number of them 
formed simultaneously, increased in size, coalesced, and in this way gave 
rise to ulcers of very considerable size. 

" Ulcers on the posterior wall of the pharynx had always an ash-coloured 
base, altered the speech greatly, were in general covered with a viscid 
greenish mucus, a portion of which flowed down when the mouth was 
opened, so as to render it a matter of difficulty to recognise them. Ulcers 
of this kind always appeared after long mercurial courses, and healed very 
slowly but with certainty." 



LECTURE XXVIII. 



" Different forms of syphilitic eruption — Methods of treatment — Affections of the bones — 
Memorandum of Dr. Fricke's practical observations on the nature and treatment of syphilitic 
diseases. 

"These were found by Dr. Fricke so various and complicated, as to ren- 
der their classification a matter of difficulty. Most of them, however, ex- 
hibited in general the characters of one of the following classes. 

"1. Pimples, at first discrete, of a bright liver colour, on a level with 
the skin in the commencement, but afterwards somewhat raised and indu- 
rated ; they appeared first on the forehead, and then on the breast and 
back, but rarely on the extremities; they were not in general covered with 
scales, or surrounded with an inflamed areola ; often formed small puru- 
lent vesicles, and rarely exceeded in size the head of a large pin. They 
generally appeared after non-mercurial treatment, and disappeared quickly 
and completely. 

"2. Brown spots, at first light, but afterwards darker, and of a copper 
hue, from two to six lines in diameter; roundish or angular, raised some- 
what above the skin, flattened, shining, and covered with scaly laminae. 
They appeared at first on the back, breast, and nape of the neck; then on 
the arm and fore-arm ; and afterwards extending over the face, forehead, 
scalp, and lower extremities, so as to give the patient a mottled appear- 
ance. When the disease went on unchecked, the spots increased in size, 



SYPHILIS. 295 

became harder and more elevated, engaged the skin more deeply, and 
when neglected passed into ulcers, or into the following class. This form 
of eruption was generally seen on patients who had taken mercury for the 
primary disease. 

"3. Very large purple spots, from one to two inches in diameter, or 
more, somew T hat indurated with outlines imperfectly circular, in conse- 
quence of their angular projections, generally single, seated on the extre- 
mities and shoulders, raised above the surrounding skin, partly raw, partly 
covered with crusts, and frequently changing into deep ulcers. They often 
appeared with the colour above mentioned, or formed small, hard, deep- 
seated purple spots, which increased in size, sometimes were formed from 
spots of the second description. They never appeared on the face, but 
always on the shoulders, and on the upper and lower extremities, were 
extremely obstinate, and always left behind them a discoloration of the 
skin. This form of eruption was observed only in cases where large quan- 
tities of mercury had been used. 

"The second and third forms were the only ones that ended in ulcera- 
tion. These ulcers were of various kinds, but in general were characte- 
rised by an unequal base, imperfect granulation, corroded edges, and an 
inflamed areola. A third form of ulceration was also frequently observed; 
this was the result of chronic abscesses, and generally occurred in syphi- 
litic cases of long standing." 

"treatment of syphilitic eruptions. 

"The treatment was extremely simple. It commenced always with 
ablutions with soap and warm water, and the purging mixture of Epsom 
salts; by these means alone the eruption No. 1 was generally cured. In 
cases of the eruption No. 2, after a few days we proceeded to the use of 
nitric acid baths (from one to two ounces of the acid to each bath), along 
with the internal use of the decoction of the woods, to the extent of eight 
or twelve ounces in the day. The diet w r as at first low, but was afterwards 
gradually improved. During the first period, the patients were confined 
to bed ; but when the eruptions became milder, they were allowed to walk 
about their rooms. When the spots became pale, the skin smooth, and 
the face and forehead clean, exercise in the open air was regarded as a 
means calculated to complete the cure. The spots on the face were moist- 
ened frequently in the day with a solution of corrosive sublimate (twelve 
grains to tw r elve ounces of water), or of nitric acid (a scruple to twelve 
ounces of water), and in milder cases disappeared so much in the course 
of four weeks as to allow the patients to take exercise in the open air. 

"The spots described at No. 3 came much less frequently under our notice, 
but they were of the most obstinate description, and were very slow in dis- 
appearing. In some cases, after employing the foregoing and other ex- 
ternal remedies in vain, w r e have derived remarkable benefit from cover- 
ing each individual spot with small blisters. As soon as the blister rose, 
and a raw surface formed, marsh, mallow, or zinc ointment, was applied, 
and cicatrization promoted as speedily as possible. After this application, 
the spots became much paler, smoother, and more like the sound skin ; 
they also became less prominent, and exhibited fewer raw patches. 

" In general, we considered the use of baths as the most valuable 
means of cure in syphilitic eruptions. The following were those chiefly 
employed : — 



296 CLINICAL MEDICINE. 

" Fresh water baths were used as well in the commencement of the 
cure, with the view of trying their effects on the eruption, as also at a 
later period, for the sake of cleanliness, particularly where there was a 
copious detachment of scurf. Soap baths (in the proportion of a pound 
of yellow soap to each bath) always constituted the first steps of treatment 
in every form of eruption. Partly, we were able to draw a tolerably fair 
conclusion from their influence on the" eruption, as to the quickness or 
brevity of its course, and partly they were found sufficient in many cases 
to effect a cure without any other remedy. From six to eight baths were 
in general found sufficient for the removal of the eruption marked No. 1, 
and from twelve to sixteen for that of some others resembling No. 2 ; in 
the commencement, at least, they exerted a favourable influence over 
all. Saline baths (composed of two pounds of common salt to each 
bath) were used only on a few occasions, and without any remarkable 
effects. 

" Vitriolated zinc baths (consisting of two ounces of sulphate of zinc 
to each bath) were prescribed with good effects in the eruption marked 
No 2, but were very seldom employed. Of nitric acid baths we have 

already spoken. 

" Sulphuric acid baths (consisting of two ounces of the strong acid to 

each, bath) exerted a favourable influence on the eruptions. 

" Corrosive sublimate baths (half an ounce of the sublimate to each 

bath) were often employed, and were of great service, particularly when 

preceded by soap and nitric acid baths. They seemed to remove the 

eruption more speedily than even the nitric acid baths. In the eruption 

marked No. 3 they did not answer our expectations. 

" Bran baths operated with remarkably good effects in the eruption 

marked No. 1 ; they also rendered the third description milder, and 

thereby contributed to diminish it. 

" During the year 1827, the venereal patients took on the whole 14 

saline baths, 38 zinc baths, 103 bran baths, 302 sublimate baths, 314 

nitric acid baths, and 330 soap baths." 

" AFFECTIONS OF THE BONES. 

" Caries of the bones was never seen in any case which had been treated 
without mercury throughout ; the bones which were most frequently 
attacked with caries were the nasal, palatine, maxillary, sternal, and 
tibial. 

" Pains in the bones were of various kinds. The following varieties 
were those chiefly observed : — 

" 1st. Fixed pains in the centre of the bones. These were generally 
felt in the bones of the shoulder, forehead, and fore-arm, but chiefly in the 
tibia. The pain was dreadful ; increased by the heat of the bed at night, 
and by the slightest touch : it in general deprived the patient of all sleep, 
and was accompanied by nodular swelling, which sometimes terminated 
in abscess and caries. 

" 2dly. Fixed pains in the ends of the bones. Sharp, lancinating pains 
were felt most frequently in the knee, ankle, and shoulder-joints, more 
rarely in the hip, elbow, and wrist-joints. These were sometimes slight, 
sometimes intense, and of an inflammatory character. They were aggra- 
vated by cold, great heat, pressure, and on the approach of night, but 



SYPHILIS. 297 

relieved by warmth and moisture, particularly the latter, which produced 
local perspiration. They were frequently combined with anasarcous 
swellings of the parts, and, when neglected, sometimes terminated in 
effusions of water or pus into the synovial membrane of the joints. 

" 3. Fixed pains in tendinous parts. — Tense lancinating pains were felt 
in the tendinous expansions and ends of the muscles, particularly those 
of the head, nape, back, and shoulders ; sometimes, but not always, 
increased by pressure, relieved by warmth and moisture, and exasperated 
by cold, particularly cold draughts of air. They resembled rheumatic 
pains, were extremely obstinate and harassing, and sometimes ended in 
partial paralysis. 

" 4. Flying pains. — These were felt in various parts of the body, in the 
head, the joints, arms, femur, and tibia, and generally appeared where 
the patient had been exposed to cold after mercurial frictions. They 
sometimes disappeared of themselves, and sometimes became fixed, but 
seldom harassed the patient so much as the foregoing species. 

" The treatment of the first species of pains was much easier than that 
of the second or third. In the first species the only thing which was 
found to be productive of certain and permanent relief, was to make an 
incision over the painful part down to the bone. As soon as this was 
done, and a poultice applied, the pain ceased and never returned. The 
incisions varied from one to two inches in length. The periosteum and 
bone were in general swollen, and the latter was often found carious, or 
covered with sanious pus. Leeches, cataplasms, and alkaline baths, were 
of little use except at the commencement, or in very slight cases. Pains 
of this description generally came on after the use of mercury, but were 
also observed in two instances at the termination of gastro-rheumatic and 
rheumato-nervous fever. Pains of the second description were treated 
antiphlogistically. When of an inflammatory character, leeches, cata- 
plasms, rest, and the free use of opium at night, in general proved suc- 
cessful. Warm or sulphur baths were frequently given, and the patient 
took nitre or the acids by day. Pains of the third kind were treated with 
alkaline or sulphur baths, tartar-emetic ointment, warm clothing, frictions, 
and when on the decline, exercise in the open air, and a cautious use of 
the cold bath. Flying pains Generally yielded to warm baths, but some- 
times required the line of treatment applied to pains of the third species. 

" Iritis and alopoecia were observed only in a few cases, and invariably 
in patients who had been treated with mercury." 

Such, gentlemen, are the conclusions at which Dr. Fricke had arrived 
when he published his Surgical Annals, in 1S2S. 

As ten years have since elapsed, during which Dr. Fricke has con- 
tinued to conduct the treatment of the venereal patients in the Hamburgh 
hospital, I took the liberty of writing to him, for the purpose of ascertain- 
ing whether subsequent experience had induced him to alter his views. 
His answer was, that instead of altering his views, experience had con- 
firmed them. Dr. Fricke, at the instance of Dr. Oppenheim, had the 
kindness to discuss some of the most important topics connected with 
syphilis, in the presence of a well-informed and intelligent young surgeon, 
a friend of Dr. Oppenheim, who took notes of what Dr. Fricke said, and 
transmitted them to Dublin for my use. These notes I now proceed to 
lay before you ; and, in doing so, I beg leave to observe emphaticallv, 
that Dr. Fricke cannot be held responsible for them, inasmuch as though 



298 CLINICAL MEDICINE. 

I believe them to be in every respect accurately taken, yet allowance 
must be made both for misconception of Dr. Fricke's meaning, on the 
part of the gentleman who took the notes, and of errors on the part of the 
translator. The latter I have endeavoured, if possible, to avoid ; for the 
translation, made originally by Dr. West, has been since carefully re- 
vised by Mr. Swift and myself, and I think, therefore, I can answer for 
its fidelity. 

It is scarcely necessary to add how much I feel obliged to Dri Fricke 
for the readiness with which he complied with my request, and the trou- 
ble he has taken to fulfil my wishes. The great hospital of Hamburgh, 
under his care, affords one of the best schools for medicine and surgery 
with which I am acquainted, and affords the best opportunity for the study 
of venereal complaints. In truth, I strongly advise students who wish to 
obtain a knowledge of Continental practice, to go to Hamburgh in the 
first instance. Half a year, or a year, spent in that city, will afford them 
more chance of obtaining sound practical information, than if they had 
repaired to Paris or Berlin. 

DR. 

SYPHILITIC DISEASES. 

(Being the substance of various oral communications in the month of November, 1838.) 

Among the German writers w T ho have contributed to advance the ra- 
tional treatment of syphilis, Dr. Oppenheim has mentioned Brunning- 
hausen, of Wurzburg, Pokkels, of Brunswick, Von Walther, of Bonn, 
and more particularly Fricke, of Hamburgh,* who published several 
papers on the subject in Rust's Magazine for 1826 and 1831, and in 
Casper's Wochenschrift for 1834. 

Subsequently, Dr. Fricke communicated, in his " Surgical Annals" for 
1828, his very important observations on the rational treatment of the 
disease. G. Handschuh (On the Forms of Syphilis and their Treatment, 
Munich, 1831), who has given an elaborate and critical history of the 
pathology, prophylaxis, and treatment of syphilis, with a view to the 
more extensive diffusion of a harmless system of treatment (a task subse- 
quently executed with more accuracy by Bonorden), often refers to these 
observations of Dr. Fricke, and attempts also to prove that under the 
name of syphilis are comprised a number of diseases, which have proba- 
bly no mutual relation, and in the treatment of which mercury is usually 
employed. Even at the present day, German practitioners in general 
repose the highest confidence in mercury. No one appears to concern 
himself about its modus operandi, or why it should be preferred to all other 
remedies in the treatment of syphilis, every one pursuing with respect to 
it the same reasoning in a circle as with respect to Peruvian bark. Bark 
cures intermittent fever, but intermittent fever cannot always be cured 
with bark. 

Dr. Fricke, however, has had no reason to abandon his new method of 
treatment ; on the contrary, further experience has not only confirmed his 
previous observations in every instance, but also a series of cases, now 

"* Dr. Oppenheim himself has indirectly, but powerfully, assailed the mercurial treatment in 
his work, ' ( Behandlung der Lustseuche ohne Quecksilber, Hamburgh, Hoffmann, and Campe, 
1837;" which contains an erudite and accurate list of all the remedies which up to that time 
had been successfully employed in the treatment of syphilis. 



SYPHILIS. 299 

amounting to several thousands, has forced upon him a conviction of the 
superior efficacy of what has been termed (but incorrectly), the antiphlogistic 
method, and at the same time has led him to new views with respect to 
the nature of syphilis, a disease exceedingly complicated in itself, and 
rendered still more obscure by the hypotheses put forward with respect to 
it, some with more, others with less, foundation. As the result of his in- 
vestigations it may be stated : — 

That syphilis has two constituents, namely, contagion (a source to which 
attention has been almost exclusively directed), and disposition , an agent 
of equal importance, at least so far as the origin, reproduction, and treat- 
ment of the disease is concerned. 

" I. PATHOLOGICAL PROPOSITIONS, 
(a) Contagion. 

" 1. Numerous experiments in which the pus of chancre was mixed 
with mineral poisons (as for instance, chlorine, corrosive sublimate, arse- 
nic, &c), or with vegetable (as cicuta, belladonna), or with the matter of 
itch or small-pox, have invariably afforded the same result, viz., the pro- 
duction of genuine chancre. Hence we may conclude, that contagion is 
something extremely subtile, and capable of maintaining its own vitality, 
and consequently that it must be very difficult to invent a preventive 
against it. Even the application of ice or heat to the inoculated spot fails 
in arresting the development of chancre.* 

M 2. The syphilitic, like all other contagions, has a tendency, when its 
course is not disturbed, to develop itself on the membranous tissues, par- 
ticularly on the confines of tissues, of different kinds, as for instance, on 
the prepuce (the normal secretion of which allows us to class it as interme- 
diate between skin and mucous membrane), around the anus, at the ter- 
minations of the intestinal and bronchial membranes, on the conjunctiva, 
a membrane which holds an intermediate rank between the mucous and 
serous. The most obstinate form, condyloma, generally selects such tran- 
sition spots or intermediate tissues. The history of contagion informs us, 
that in prevalent and severe cutaneous affections, it is the result of contact 
between individuals in different states ; and the practice of medicine 
teaches us that attention to the skin, or, in other words, cleanliness, is be- 
yond doubt one of the most efficient remedial agents, and its observance 
a main condition of cure. Mercury, with its pseudo-syphilitic cutaneous 
affections, as well as all other antisyphilitic remedies in repute, promote 
or produce directly an excitement of cutaneous activity. Nodes, indepen- 
dently of being the reflex action of the disease on the periosteum (a mem- 
brane which belongs rather to the secreting than the dry fibrous tissues), 
form no argument against this position. 

u 3. True crises are scarcely to be expected or observed in chronic dis- 
eases of the skin. We should, however, always bear in mind, that the 
constitution requires a certain degree of power to react against contagion, 
and resist the morbid process which the latter endeavours to establish ; and 
that this power is least of all to be interfered with where the existence of 
a morbid predisposition, but more particularly of the scrofulous diathesis 

* " Eisenraann asserts on some occasions, but, erroneously, that the admixture of corrosive 
sublimate destroys the syphilitic virus. Fire certainly destroys it, but still it is not an anti- 
syphilitic. 



300 CLINICAL MEDICINE. 

is likely to destroy its due balance. In such cases mercury is positively 
injurious. 

"4. The contagion of syphilis seems to possess a certain degree of pro- 
tective power against the same disease. Thus if an infected person be 
inoculated with the virus, he is much less likely to take the disease than 
a healthy uninfected person. In this, however, the local and general con- 
dition of the system which occurs during coitus, and strongly disposes to 
the reception of contagion, plays an important part. If, however, a per- 
son affected with chancre were inoculated with the matter of that chancre 
on a fresh spot, and from this on a third and so on, it will be found that 
this process can be repeated only a few times with success. The indivi- 
dual becomes, as it were, habituated to the virus, and less susceptible of 
its influence. In the same way no secondary affections are capable of being 
propagated by inoculation. May we not, then, look upon these affections 
as a salutary effort of nature to check the progress of the disease? The 
relative immunity, too, enjoyed by some females, seems to depend upon 
the constitution being, as it were, stimulated to reaction, and spontaneous 
cure by a second contagion. In persons of this kind, an inveterate lues, 
that is, a modification of their whole organic system by the syphilitic con- 
tagion, may exist for a long time without offering a single point of attack 
for therapeutical agency. Even connection with such individuals, pro- 
vided they are free from local sores, is not dangerous to others. 

" 5. How long the period of incubation of the contagion may last, is by 
no means determined ; there are cases in which a connected series of symp- 
toms of alternate improvement and aggravation points out the struggle of 
the constitution against the contagion, the latter ultimately gaining the 
ascendency and exhibiting itself more and more in fresh secondary affec- 
tions. Often, however, these affections breaking out after a number of 
years, are not of a truly syphilitic character, but the result of a cachexy 
produced in a system already undermined by previous attacks of syphilis, 
and by a variety of noxious influences which develop morbid diathesis, or 
bring into play acquired predispositions. Hence, in all localities favour- 
ing the production of cachexies, we find peculiar forms of disease which 
we are forced to look upon as syphiloid, inasmuch as they present the same 
modified forms of scrofulous and impetiginous disease in which syphilis is 
known to have the initiative — a property shared by it in common with 
measles, small-pox, and all other contagious affections. In such a case 
as this, to attribute the whole series of morbid phenomena to the previous 
syphilis would be as incorrect as to regard growth as the sole cause of 
phthisis. Growth merely develops an original disposition, viz., the phthi- 
sical ; and we have only to suppose that the disease existed in a latent form 
to avoid all error on the subject. 

"6. The original seat of contagion is either the mucous membrane of 
the genital organs and its mucous follicles, or the chancrous, i. e. a portion 
of external skin brought into the condition of a mucous membrane. 

"7. No advantage to the treatment of syphilis results from making dis- 
tinctions between its primary forms, and particularly between gonorrhoea 
and the syphilitic virus. They all get well under the (so-termed) antiphlo- 
gistic treatment. The mucous membrane of the male genitals, which oc- 
casionally becomes violently inflamed, and secretes copiously and obsti- 
nately from the mere introduction of bougies, or the matter of non-syphi- 
litic biepharophthalmia, is irritated by the sylphilitic virus just as it is by 



SYPHILIS. 301 

these foreign chemical or mechanical influences. Gonorrhoea, however, 
for the most part has its origin in other morbid sources (leucorrhoea, the 
period of menstruation, before and after the same, &c.) which are modified 
solely by coitus, by it produces a noxious effect on the system, and with- 
out it are to be looked upon as harmless. We have not hitherto been able 
to tell by the appearance of the discharge from what source it arose. The 
conjunctiva is much more frequently observed in a purely inflammatory 
state than the mucous membrane of ihe urethra. 

u 8. Sometimes, but very rarely, we observe a transition from gonorrhoea 
to chancre. In 200 cases in which inoculation with gonorrhceal matter 
was performed, there were only two instances of chancrous sores as the 
result. A greenish yellow discharge from the uterus produced by inocu- 
lation genuine chancre, and gave rise to gonorrhoea when introduced into 
the male urethra by means of a fine bougie. 

11 9. The importance of bearing in mind the disposition is still further 
shown by Richter's supposition of the existence of a gonorrhceal lues 
[Darstellung der Scheinbaren Aehnlicalceit unci wesentlichen Serscheidenheit 
Zwischen Tripper und C hanker, Leipsig, 1819), and Autenrieth's of a 
gonorrhceal scrofula (Tiibinger Blatter fur J\aturwissenschaft, &c. Band I 
Aeft 2). Every disease affecting the whole system, and syphilis and 
gonorrhoea among the rest, is capable of awakening dormant predisposi- 
tions ; hence syphilis or gonorrhoea may give rise to tumours of the joints 
and nodes in persons of a rachitic, or rheumatic constitution. The sym- 
pathy between the kidneys and urethra is remarkable in one point of 
view, namely, that in gonorrhoea the urine is found to contain a large 
quantity of albumen. What the consequences may be of the removal of 
so much albumen from the system, whether it be a species of natural an- 
tiphlogistic, or whether chemical analysis can prove the existence of a 
deficiency of albumen in the blood, is not yet determined ; it is a condi- 
tion, however, which has been observed in connection with many forms of 
cachexy. The mental impression caused by gonorrhoea — the almost in- 
curable hypochondria syphilitica — indicate some important alteration in 
the admixture of the fluids. The interesting observations of Gueterbock, 
W 7 ood, Vogel, and Henle, on mucus and pus, establish for mucus (inas- 
much as it is now to be distinguished from pus) a high rank among the 
organised fluids, and, in fact, the albumen ovi, which bears an analogy 
to the mucus of the genitals of the mammifera?, is a species of pus or 
mucus secreted by the oviduct, and of great importance in the generation 
of the bird. 

"(e.) disposition. 

" The state of the system, and in particular of the cutaneous tissue, is 
deserving of consideration, not only during coitus, but also during the 
whole course of the disease. Many persons will not take the disease 
either by coition or by inoculation, and in general, persons in a tranquil 
healthy state will not receive the contagion even when the virus is brought 
into contact with abraded surfaces. Dr. Fricke on one occasion, while 
examining a gonorrhceal patient, had the whole contents of an urethral 
lacuna squirted into his eye; simple ablution of the part prevented all 
bad consequences. 

The delicate skin of fair persons and that of the negro favours the re- 
ception and spread of contagion ; the same is the case with persons of a 



302 CLINICAL MEDICINE. 

dirty greasy skin, or where the functions of the skin have been injured by 
an unquiet life or by change of climate. Hence the inhabitants of northern 
climates, who in general seem to exercise a stronger reaction against con-r 
tagion, suffer much more when they visit more southern regions. Hence 
also the rich suffer less than the poor. Persons of a sanguine tempera- 
ment are in general the most susceptible ; the whole system in such per- 
sons, and the mucous membrane in particular, being in a state of excite- 
ment. France would suffer less from this disease were it not for the slight 
attention paid to the skin, and the use of mercury. 

" The scrofulous and rachitic, the rheumatic and gouty diathesis, the 
predisposition to lupus and herpes, have alike an influence in determining 
the form of what has been termed secondary syphilis. As there exists in 
some individuals a complicated predisposition to sore throat, probably de- 
pending on a scrofulous diathesis, the predominance of the mucous tissues 
and gastricism, the eruption of ulcers of the throat, may be apprehended 
under the following circumstances : — The throat is narrow, the tongue 
arched, and with difficulty pressed down in the mouth ; the back of the 
throat cannot be seen without exciting nausea, the mucous membrane 
secretes copiously and is covered with moisture ; the soft palate is'; of a 
more or less deep red colour, the arches of the palate hang very low down, 
the glosso-palatine higher than the pharyngo-palatine ; the uvula, which 
in the normal condition has only a red stripe down its centre, is of a uni- 
form red colour, covered with mucus, and adheres readily to either of 
the tonsils; the latter stand near each other, are red, and covered with 
a viscid mucus; the whole mucous membrane of the throat is very sen- 
sitive, secretes more copiously when the mouth is kept open, and becomes 
redder as if new vessels became suddenly developed in it. Under such 
circumstances we may naturally expect ulcers in the throat; under oppo- 
site conditions we look for them in vain. Sometimes the mucous mem- 
brane of the choannse becomes indurated, applies itself to the tonsils, and 
produces excoriations, which however heal under the use of emollient 
injections. The occurrence of fresh catarrhal and gastric derangements 
seem to have a considerable influence in bringing about all syphilitic me- 
tastases, or at least direct the force of the morbific process to parts already 
weakened and predisposed. The predisposition to buboes depends upon 
other causes as well as scrofula ; among these we may mention much 
walking or bodily exertion. Women are more liable to these glandular 
affections than men ; persons of spare habit and firm fibre, as also persons 
labouring under hernia, in whom the parts subjected to constant pressure 
from a truss, seldom suffer from them unless they happen to be in a highly 
cachectic condition. Not unlike bubo in many respects is the disease 
termed orchitis blennorrhagica (inflammation of the epididymus, and in- 
filtration of its substance w 7 ith organised lymph, owing to the extension 
of urethritis sympathetically or by metastasis) an occurrence which may 
be expected when we find the vas deferens becoming swollen and painful. 
The testicle itself remains during the whole time unimplicated ; it is, 
however, frequently displaced, and hence, in order to detect it, the part 
must be examined very closely. The lymph is infiltrated so completely, 
and becomes so intimately combined with the substance of the epididymis, 
that the consequent hardness in many instances will not yield to any re- 
medial agency, and though it may be somewhat reduced by compression, 
it remains quite perceptible even after the lapse of twenty years. 



SYPHILIS. 303 

There exists naturally a sympathy between the mucous membrane and 
the skin. An exanthema is sometimes produced not only by balsam 
copaiba, but also by turpentine, for the cure of gonorrhoea. The syphi- 
litic cutaneous affections depend partly on the virus being either wholly 
neglected or imperfectly cured, or, as is frequently the case, aggravated 
by the abuse of mercury, partly on the sympathy already alluded to. The 
peculiar form of the eruption depends partly on the condition of the skin, 
and partly on what has been termed the acrimony of the fluids or dys- 
crasy. Persons of a dark complexion and a dirty freckled skin are most 
liable to these eruptions. Itch appears to have less power in modifying 
the eruption than other dyscrasies, as, for instance, the herpetic. The 
occurrence of gonorrhoeal ophthalmia and of syphilitic iritis furnishes 
strong proofs of the existence of a species of elective affinity, of an un- 
known metastasis from one diseased tissue to another predisposed to dis- 
ease. The former affection, if it be produced by infection from contact, 
should be more frequent. Interruption of the urethral discharge is never 
the cause of epididymitis (on the contrary, inflammation of the epididymis 
and the parts in its vicinity acts as a derivative on the gonorrhoea, and 
arrests its flow), much less can it be exclusively the cause of inflammation 
of the remote conjunctiva. Hence we must ascribe to this membrane 
(forming as it does a transition membrane between the mucous, serous, 
and cutaneous tissues) a greater predilection for the virus of clap, than to 
the mucous membrane of the ear or nose. It is quite plain that iritis 
arises without contagion, and without any other metastasis than that com- 
mon to all syphilitic affections. Indeed, it comes on frequently after a 
protracted treatment either with or without memory. The iris conducts 
itself here like the fibrous periosteum ; it is not affected until some time 
after the external tissues of the eye, which afforded, as it were, a kind of 
point of attraction for the disease. There exists also a peculiar disposition 
to condylomata as pseudo-products, among which the conical condylomata, 
as being parasitic productions endowed with remarkable vitality, present 
the characters of the contagion in the highest degree. Whether the pa- 
thological process by which they are generated be the same as that by 
which the fungosities of ulcers are formed, and whether their bases be a 
structure intermediate between polypus and wart, remain still undecided. 
Dr. Fricke saw them appear as the harbingers of more serious affections, 
as, for instance, of fungus medullaris of internal organs. Prof. Otto (in 
his Diinischer Zeitsc.hr if t, 1838, Heft 2) relates an instance of their pro- 
duction as the result of unnatural coitus between two persons perfectly 
free from syphilis. Rognetta (Gazette Medicate de Pans, June, I836)de- 
scribes a species of warty growth from the anus, which might have passed 
for condylomata had not the chastity of the individuals been well known; 
hence we are not in all cases of condylomata to assume the pre-existence 
of syphilitic contagion. Again, with the tendency to form condylomata 
there coincides a tendency in the skin to form warts and corns — a ten- 
dency the source of which is probably seated in the mucous membrane of 
the kidneys, or of the digestive apparatus in general. The iiat condylo- 
mata heal readily, but the conical* can by no means be destroyed, so that 
we are forced to leave them alone and let them wear themselves out. 
They prove themselves to be a mere secondary syphilitic formation by 
this fact, — one cannot produce chancres from them : the moisture exuded 
by them produces only excoriations and condylomata of the parts with 



304 CLINICAL MEDICINE. 

which it comes in contact, just as all acrid secretions do, and any secre- 
tion may be regarded as acrid to all parts to which it is not the natural 
stimulus. The primary and secondary condylomata are very similar; the 
circumference of the former, however, is less than that of the latter, and 
their secretion not so copious. 

" With regard to affections of the bones (the occurrence of which indi- 
cates that the system has yielded to the morbid influence of the syphilitic 
poison), affections, too, which make their appearance in persons disposed 
to cachexies, who have scarcely escaped rickets, and who have already a 
tendency to rheumatism and gout, even here mercury is not free from all 
blame as a cause. This opinion is supported by the power which mercury 
has of destroying vitality, and hence of destroying the vitality of pseudo- 
products, by the circumstance of mercury in the reguline state having 
been found in the bones (Chirur. AnndL loc. cit.), and the fact that these 
affections disappear on the occurrence of symptoms of salivation. 

" It is an undeniable fact, that syphilitic affections, and even ulcers 
resembling chancres, or the sores produced by inoculation with the matter 
of chancre, may be congenital ; but it rarely happens that infection takes 
place during birth, much as the condition of the child's skin might seem 
to favour the reception of the virus. Women labouring under syphilis in 
a very high degree, give birth to children which are healthy, and con- 
tinue so, just as occurs with mothers affected with herpes and other mor- 
bid predispositions. Where discharges o*r eruptions of a syphilitic cha- 
racter appear immediately after birth, they have already lost their conta- 
gious property (they cannot be reproduced by inoculation), and this seems 
to favour the opinion that the syphilitic contagion acts much more than 
others as a mere morbid stimulant, producing no peculiar cachexy, and 
merely maturing or modifying pre-existing morbid diathesis. Thus a scro- 
fulous person, by means of syphilis, becomes more or less truly scrofulous, 
and, in many cases, for the first time only at. a late period, and where his 
health has been disturbed by other causes, after the actual cure of the 
syphilitic affection. It is then not syphilis, but the original morbid dia- 
thesis modified by syphilis, which becomes propagated. Hence, in de- 
ciding on a plan of treatment, this diathesis, or, as we have termed it, 
disposition, is the chief point for consideration, and hence also results the 
curability of syphilis by so many different*means. The same thing holds 
good with respect to what are termed relapses, which occur under every 
form of treatment, and more frequently under the mercurial, because 
where there is hereditary predisposition, a new morbid stimulant will be 
given to scrofulous, herpetic, rheumatic, and gouty affections. Hence, 
too, the origin of those exceedingly obstinate chancrous ulcers of the pre- 
puce, constantly reappearing after imperfect cicatrization, and conse- 
quently after detachment of the cuticle. The edges, for instance, remain 
callous,* hence slight motion is sufficient to break open again the badly 
healed ulcer. In the latter case cataplasms, in the former astringent 
applications, to diminish the sensibility of the prepuce, produce the best 
effects. 

" II. THERAPEUTICAL PRINCIPLES. 

" To establish the rationale of treatment, it would be necessary to attain 
a knowledge of the origin of the contagion ; the mere treatment, it is true, 

* It is a mistake to regard this callosity of the edges as foreboding the occurrence of 
secondary symptoms. 



SYPHILIS. 305 

does not require that any regard should be paid to the contagion ; it can 
be cured without it, and mere experience will lead to the establishment 
and proof of a counter-poison and a real poison. But the theory of treat- 
ment requires this consideration. How, then, are we to ascertain the 
nature of the virus ? The period of its origin may be more certain than 
the place, but the period is as remote as the persons who first observed 
the disease, and the constitutions which presented themselves for observa- 
tion.* The following facts, however, demand our attention : — 

" 1. The contagion results from the contact of different individuals, and 
of the external skin or semimucous membrane of the male with the mucous 
membrane of the female ; 

" 2. It is promoted by the mucus of the female, which is inclined to 
acrimony, and which, as well as the seminal fluid of the male, is a highly 
vitalized product, and looked upon as contributing to vital development ; 

" 3. By the mixture and mutual neutralization or solution of different 
spermata, as well as by their predominant constitutional influences ; 

" 4. It is received when the sensibility of the part is in the most exalted 
state ; 

" 5. It shows its action more especially on all the sensible organs of 
reproduction, modifies (as has been already stated) every morbid disposi- 
tion, or matures and stimulates the existing disposition to increased action 
or pseudo-production. 

" Now, if bearing in mind what we learn from physiology and thera- 
peutics, we call the contagion a pseudo-spenna, or in other words, a pecu- 
liar albumen, the result of the exercise of the generative function, we 
thence get an explanation, 1st, of the congestion which it produces in the 
generative organs, as in gonorrhoea ; 2d, of its tendency to attack and 
involve all the reproductive tissues, especially the skin ; 3d, of its ten- 
dency to the formation of pseudo-products ;f 4th, of its tendency, proved 
also by the history of the embryo, first to attack sensible parts ; 5th, then 
to develop itself according to certain antithesis (poles or metasta-sis) ; 6th, 
the indications for treatment, the happy results of which afford a further 
conclusion as to the nature of the disease r as well as an explanation of the 
success of other methods, and particularly of mercury. 

" The method of treatment to be employed deserves the name of the 
antiplastic. Sudden weakening of the system by venesection is, with a 
few exceptions, wholly unnecessary ; on the contrary, the constitution 
may at first require a generous diet to enable it to sustain the reaction ; if 
during its continuance the sores increase, they disappear so much the more 
speedily afterwards, when the abstinence cure is commenced. This, how- 
ever, need not be made a complete hunger-cure,, and perhaps it has been 
laid down too strictly in the Chirurg. Jlnnalen ; the severity of it should 
be lessened in proportion to the patient's improvement. On the other 
hand, a too careful or solicitous attention to cleanliness cannot be shown.} 
Rest is an excellent anaplastic. During its observance, chymification and 

* Pitschaft (Hufeland's Journal for March, 1838) quotes some old German verses of 1472, 
about king Wenzel. in which it is stated, that after drinking mum, he was attacked with putre- 
faction of the genitals, and died. 

j- The well-known Kleeblatt, so often found in the ovary, the hair, fat, and teeth, probably 
bear some analogy to syphilitic diseases of the skin, mucous membrane, and bones. 

t " From this cause, as Dr. Fricke has often convinced himself, the rational method often 
fails in private practice. We are not able to enforce cleanliness, which is generally attended 
with pain, and we are obliged to trust too much to the patient's statements." 

21 



306 CLINICAL MEDICINE. 

assimilation are less active ; all the functions are carried on with less 
energy ; and thus the contagion, neglected, as it were, and limited in its 
seat, dies out of itself. Of itself it possesses naturally but little power, 
and where cleanliness and regulation of the diet are attended to, as well 
as a proper regard paid to the peculiar disposition of the patient and the 
course of the disease, rest may be less strictly enforced after the lapse of a 
few days. A plentiful meat diet is apt to bring on buboes, while a strictly 
vegetable diet tends to give rise to condylomata. Internally, it will be 
sufficient to administer Epsom salts in such doses as to produce a few 
evacuations daily, and even in this point we may abate a little in our ori- 
ginal strictness after a few days. Decoction of sarsaparilla, infusions of 
senna or Carica arenaria, and the acids, paaticularly the nitric, are also 
employed with advantage. Hydriodate of potass, either with or without 
decoction of sarsaparilla, is an admirable remedy, and greatly esteemed 
in many parts of Germany. 

u Mercury, even supposing that it did not exercise a more injurious 
effect on the system than Peruvian bark, must, as a specific, militate 
against a sound knowledge of disease (for all specifics lead to a false sys- 
tem of therapeutics), and particularly of syphilis, in which every thing 
depends on individualizing and accurately examining the morbid predis- 
position. The secondary forms in particular require a regulation of those 
functions whose disturbance constitutes the source of the disease, and 
consequently a regulation of diet in the strongest sense of the word. The 
stomach and skin are the two organs which are chiefly deranged. The 
same plan of treatment which we would follow in treating cases of herpes, 
scabies, scrofula, gout, rachitis or periostitis, depending on ordinary causes, 
must be also followed where these diseases have been called into exist- 
ence by the syphilitic virus. On the whole, however, secondary syphilis 
is rarer than is generally imagined. Neither secondary symptoms nor 
relapses require treatment different from that which is adopted in the cure 
of primary symptoms ; a treatment, the chief features of which are, that 
it is external, not opposing or obstructing nature, but rather assisting her 
by cleanliness, &c. Fresh air often cures cutaneous affections in a short 
time ; condylomata disappear after the lapse of a certain time under the 
use of a variety of escharotics, without our being able to fix on one as a 
specific. At all times regard should be paid to morbid states of the con- 
stitution, and morbid temperaments, and we should take especial care not 
to excite any cachexy in the patient. A mild limitation of vital activity 
is sufficient to cut off all support from the morbid parasitic action, or at 
least to obviate all unfavourable influences. 

" A minute account of the modifications which have been made in the 
treatment described in the Chirurg. Annalen would require a treatise as 
long as that in which they were originally set forth. We must therefore 
refer to this work, as it would require a whole book to give the results 
of a thousand registered cases." 



SYPHILIS. 307 



LECTURE XXIX. 



Dr. Struntz's observations on the non-mercurial treatment of syphilis — Result of Dr. Oppcn- 
heim's inquiries — Opinions of Dr. Staberoh — Further remarks on the venereal disease. 

At our last meeting I gave you the results obtained at Hamburgh, by Dr. 
Fricke, respecting the non-mercurial treatment of syphilis. To-day I 
shall commence with extracts from a paper published in the Berlin Medi- 
cal Gazette, by Dr. Struntz, and although I cannot agree with the learned 
doctor in all the conclusions he has drawn, yet his facts are too valuable 
to be passed over in silence. 

The following is the sum of Dr. Struntz's observations on the non-mer- 
curial treatment of syphilis iu the venereal wards of the Charite Hospital 
at Berlin. These observations extend over a space of twelve months, and 
were made under the direction of Professor Kluge. 

Of 741 patients (some of them greatly neglected), Dr. Struntz has not 
met with a single case in which the non-mercurial plan has not succeeded, 
when combined with a rational consideration of the peculiarities of the 
local disease. On the other hand, he has seen many out-patients treated 
with mercury for weeks and months together without any advance being 
made towards the healing of primary sores, or, in many instances, with- 
out any effect in arresting their destructive progress. The primary symp- 
toms more particularly alluded to, are chancres and acuminated or broad 
condylomata. 

In the Charite Hospital at Berlin, not only primary sores, but all forms 
of the disease, from the slightest to the most intense, have been treated 
for the last half-year without mercury. It might be objected to the non- 
mercurial plan of treatment, that it does not afford any protection against 
a recurrence of the disease — that it does not ward off secondary symp- 
toms. This may be very true, but neither does mercury. Among the 
many hundred patients who came under Dr. Struntz's notice during the 
course of a year (and to this point he paid the most particular attention), 
there was not a single case of secondary syphilis in which he did not dis- 
cover, either from personal examination, or from an inspection of the pre- 
scriptions brought by the patients, that mercury had been used for the 
primary affection. If mercury, then, will not secure the patient from 
secondary symptoms, it is not unreasonable to have recourse to another 
plan, which, at most, cannot be attended with more unfavourable results, 
and which is free from the disadvantages of generating a double poison 
in the system. It is true that by proper attention to diet, rest, cleanliness, 
the avoidance of exposure to cold, and other precautions, most of the bad 
effects of mercury may be obviated ; but how are we to secure the fulfil- 
ment of these conditions among the poorer class of patients outside the 
doors of a hospital ? 

Again, is the diagnosis of syphilitic ulcers so easy, that a man can pro- 
nounce at once that this or that ulcer is a true venereal chancre ? How 
much observation and experience are required to enable a man to decide 
this apparently simple question ! Is it not well known to every practical 
and experienced surgeon, that sores are frequently seen on the genitals, 



308 CLINICAL MEDICINE. 

not produced by syphilitic infection, and yet presenting almost all the 
characters of syphilis ? 

" The results obtained at the Charite were most satisfactory. All cases 
of primary sores, including condylomata (two-thirds of which are looked 
upon as primary symptoms), were treated successfully without mercury. 
The number of patients discharged cured, was 733, and of these Dr. 
Struntz had not met with a single case of secondary symptoms up to the 
period of publication (Sept. 30th). Many of these patients were prosti- 
tutes, and constantly under the surveillance of the hospital surgeons. Dr. 
Struntz does not wish to intimate that he places implicit reliance on the 
non-mercurial treatment pursued at the Charite, or that the method is 
infallible ; all he wishes to say is, that of all the primary cases treated in 
this way at the hospital, not a single one was followed by confirmed lues, 
or even by those milder forms of the disease which have been described 
by Bonorden and others.as secondary syphilitic exanthemata. Both modes 
of treatment were followed at the Charite, but it was found that under a 
similar management of the local affections, those patients who were treated 
with mercury could not be discharged for two or three, or even four weeks 
later than those who had not taken any mercurial preparation. It is true 
that condylomata are apt to return, but this occurrence takes place as often 
under the mercurial as under the non-mercurial treatment, particularly 
when the local treatment has been commenced before the condylomata 
have completed their development, or where they have not been com- 
pletely eradicated at first. In cases of syphilitic exanthemata, psoriasis 
and impetigo, where corrosive sublimate and red precipitate had failed, 
Zittmann's decoction was used with good effects ; latterly, however, Dr. 
Struntz has been in the habit of giving the Decoct. Sarsaparillae, Caricis 
Arenarise, Specierum Lignorum, aa gij..; Fol. SennaB, 3J. Of this decoc- 
tion a pint was administered daily ; and, in conjunction with warm baths, 
and in more obstinate cases with nitric acid, he succeeded in accomplishing 
the desired effect. " It maybe observed," says Dr. Struntz, " en passant, 
that in many cases, after, and during a course of mercury, particularly, 
red precipitate and corrosive sublimate, I have seen psoriasis guttata and 
impetigo sparsa arise ; the former disappearing after the mercury had 
been omitted. Latterly we had also some cases of ulcerated throat, and 
commencing ozsena with mercurial complication. It may appear some- 
what bold in cases of this kind to exchange an old and esteemed remedy 
like mercury for sulphate of magnesia ; but in our patients, the racking 
pains of the head and nose were relieved, the discharge ceased, and the 
ulcers healed in a remarkably short space of time. About the commence- 
ment of July three young men were admitted into the venereal wards. One 
of these had been under a course of calomel and corrosive sublimate pre- 
vious to his admission ; the others had also taken a considerable quantity 
of mercury, and were labouring under ozaena and periostitic pains. By 
the use of sulphur baths, the hospital decoction, and a nutritious diet, all 
w T ere greatly improved in the space of a fortnight, and their improvement 
went on so rapidly that one was dismissed cured at the end of the month, and 
the ulcerated sore throat was beginning to cicatrize. A case of syphilitic 
iritis is deserving of notice. 

" A servant girl had been admitted in the August of the preceding 
year, for condylomata, which extended from the orifice of the vagina to 
the anus. She had been treated with calomel, and afterwards with 



SYPHILIS. 309 

corrosive sublimate, and the condylomata were either cauterized or 
removed by excision, but stiil returned as fast as they were destroyed. 
She then took Zittmann's decoction without benefit, and after some time 
reverted to the use of calomel. Scarcely had her mouth become fully 
affected (she had taken 7 doses of 10 grains each), when she was attacked 
with an impetiginous eruption of the face, and soon after with iritis, 
bearing all the characters of a syphilitic inflammation. Bloodletting, 
leeching, and antiphlogistic measures were employed, but in spite of 
every precaution, an abscess formed on the iris. The calomel having 
proved useless, was discontinued, and the patient ordered the Decoct. 
Lignorum Specierum of the Pharmacopceia Militaris, combined with a 
mild antiphlogistic treatment. Under this treatment, the pus, which lay 
at the bottom of the anterior chamber, was reabsorbed in the space of a 
fortnight, the pupil resumed its natural form ; in a word, all the traces of 
iritis had so completely disappeared, that many professional men could 
not distinguish the sound from the previously diseased eye unless it 
was pointed out to them. She was completely cured of her obstinate 
primary symptoms by the non-mercurial plan. I cannot decide what 
share mercury may have in the production of these secondary affections, 
but I cannot believe that it is wholly without influence on their origin." 

Such, gentlemen, are the facts recorded, and the observations made, 
by Dr. Struntz, to which I shall now add the contents of a letter which I 
have lately received from my friend, Dr. Oppenheim, of Hamburgh, — a 
gentleman, whose extensive practical experience., derived from upwards 
of a thousand cases, entitles his opinions to the most attentive considera- 
tion : — 

"Hamburgh, Nov. 26, 183S. 

"My dear Graves, — On receiving your letter I endeavoured to fulfil 
your wish, and the result of my endeavours is the following sketch. I 
fear it will not give you full satisfaction, being rather theoretical than 
practical, but it was impossible for me to examine all the Hospital Re- 
ports and cases in so short a space of time. I have, therefore, commis- 
sioned a very industrious young physician to communicate the points held 
in view in Fricke's treatment, and the following manuscript is the re- 
sult :— * 

" In Hamburgh the number of non-mercurialists increases daily ; among 
the young physicians, who have been practitioners for the last eight 
years, there are only two or three mercurialists. In fact, I very seldom 
meet with truly malignant and inveterate cases, and these are always cases 
in which a great deal of mercury has been taken previous to admission 
into hospital. For such cases, as exanthemata or lepra syphilitica, broad 
condylomata, nodes, tophes, syphilitic gout and rheumatism, I know but 
two remedies, which I employ alternately, according the constitution, age, 
season of the year, circumstances of the patient, &c, viz., Zittmann's 
decoction, repeated if necessary at intervals, and the external and inter- 
nal use of hydriodate of potass (jss. — 5J. in the 24 hours). 

"Disease of the bones, or of the periosteum, I have not met with in 
any case, in which the patient had not taken any mercury. 

" With respect to chancres, when in the first stage (the chancre-vesi- 
cle), I touch them with caustic ; afterwards the treatment is regulated by 
the degree of inflammation (painfulness) present. Rest (the recumbent 
* This manuscript has been published in the preceding lectures. 



310 CLINICAL MEDICINE. 

position) and diet are most important means ; the large mound-like indu- 
rations are best treated with poultices. One of the best applications for 
promoting the healing of chancres is copper, in the form of Kochlin's so- 
lution, diluted according to the sensibility of the patient. 

" Recent buboes I endeavour to disperse by abstraction of blood and 
compression ; when these means fail, and they become chronic and indo- 
lent, with an inclination to suppurate, the superincumbent skin is covered 
with Lap. caustic, chirurg. (more rarely a blister), which produces either 
dispersion and reabsorption, or healthy suppuration. 

" With respect to the frequency of secondary symptoms, private prac- 
tice affords us no information. From our hospital experience, they appear 
to be not more frequent than under the mercurial treatment ; but the form 
is different; that is to say, there is less venereal sore throat than exanthe- 
mata. 

" Gonorrhoea is a most annoying form of disease — it is cured, and is 
not, by every plan of treatment. Copaiba, in various forms and combi- 
nations, after the inflammatory symptoms are removed, prove more ser- 
viceable than cubebs. In gleet most advantage is derived from keeping 
a bougie in the urethra. 

"Melancholia syphilitica is a frightful disease, one for which there is 
often no remedy to be found, and under which the patients pine away. 

" This, my dear Graves, is the substance of my brief communication ; 
but I shall always feel most happy in answering any questions you may 
propose. With respect- to Copenhagen or Berlin I cannot give you any 
information, except, that in the Charite, Kluge has renounced mercury." 

To render the subject more complete, I shall now give the opinions of 
my respected friend, Dr. Staberoh, of Berlin, as communicated in a letter. 

Extract from a letter from Dr. Staberoh to Br. Graves, dated October 

25th, 1838. 
" In the hospital at Berlin, called the Charite, syphilitic patients are 
still treated without mercury; even in the worst cases its employment is 
less frequent than in Hamburgh, under Fricke. According to the pub- 
lished reports, the results of this treatment are very favourable ; these re- 
ports you will find in detail in RusVs Magazine, and also an extract from 
them in KleinerVs Repertorium. But, however favourable these reports 
may be, one curious circumstance must be borne in mind, viz., that sec- 
ondary syphilitic affections are not usually admitted into the hospital des- 
tined for venereal patients, but sent into the wards of the surgical clinic, 
so that in the venereal department, the great majority of cases which 
come under treatment are primary affections. These patients are dismissed 
as soon as cured, and they scarcely have in the Charite any means of as- 
certaining the frequency of secondary affections. The published reports 
naturally take a colour from the opinions of the physicians who are op- 
posed to the use of mercury, and those who visit the wards have seldom 
an opportunity of watching accurately the progress of the cases. I am 
not aware that any comparative trials have been made between the mer- 
curial and non-mercurial plans. Such may have been instituted formerly, 
but certainly on an insufficient scale. No persons could have better op- 
portunities of making them than the army surgeons, particularly since the 
inspection of the genitals, directed by law, brings the syphilitic affections 



SYPHILIS. 311 

of soldiers under their observation from the very commencement. In 
order to obtain as accurate an account as possible of the treatment of sy- 
philis in the army, I addressed myself to the l General Arzt,' Lohrneyer. 
However, strange to say, there is no printed account of the matter, and 
the reports which are in existence are of such a nature as to preclude the 
possibility of stating any thing definitely. Most of the old army surgeons 
treat syphilis with mercury, but many of those lately appointed, and who 
were on the Hospital Staff when Professor Kluge followed the non-mer- 
curial plan of treatment, do not employ mercury. They are also satisfied 
with their treatment, although it is said that in some instances they have 
had recourse to mercury in consequence of the failure of the simple method. 
Even were it in my power to give numerical statements they would prove 
nothing, since the decision of the question would depend on submitting 
an equal number of cases to the two modes of treatment. 

u As the army surgeons are not bound to any particular mode of treat- 
ing syphilis, it would be easy for them to institute such comparisons, if 
they were conducted without prejudice. In England, physicians and sur- 
geons in extensive practice are generally connected with hospitals also ; 
the case, however, is quite different at Berlin. I cannot refer to Dr. 
Kluge's private practice, for he does very little in town ; and I am ac- 
quainted with only one eminent physician who treats syphilis without 
mercury — and after all, his private practice is not large enough to warrant 
our drawing from it any conclusion. Medical men are divided on the 
treatment of syphilis ; the physicians, however, in largest practice use 
mercury without looking on it as a specific. I know a physician who 
tried the non-mercurial plan on a small scale, without its results inducing 
him to change his plan of treatment. After all, if the want of confidence 
in the non-mercurial treatment expressed by the physicians here proves 
nothing, it says but little in favour of the results obtained at the Charite, 
and which even have been adduced by some as instances of an inefficient 
method. In conclusion, I shall just sum up the results of these imperfect 
statements, which I have not attempted to render complete, knowing that 
they will arrive too late to be of service. 

" 1. The syphilitic patients in the Charite take no mercury, while in 
the venereal wards under Dr. Kluge's care. 

" 2. In the surgical wards where most of the cases of secondary syphi- 
lis are found, and to which no primary cases are admitted, the patients 
are treated with mercury. 

" 3. Any statement of the proportion of relapses in the cases treated at 
the Charite after the non-mercurial plan, must be very uncertain, if not 
impossible to be ascertained. 

" 4. In town, the mercurial is employed in preference to the non-mer- 
curial treatment. 

" You are, without doubt, acquainted with the publications of an army 
surgeon, Dr. Bonorden, at least through the abridgment in KleinerVs Re- 
pertorium. He, too, seems not averse to the non-mercurial plan of treat- 
ment ; and most practitioners speak of it with respect, although they do 
not follow it. Professor Krukenberg, of Halle, was, at least a few years 
since, a strenuous defender of this plan, and alluded to the employment 
of mercury as an instance of prejudice. Many of his pupils have brought 
these ideas with them into practice, but I have not as yet seen any bril- 
liant results from them. The case may be the same as with all absolute 



312 CLINICAL MEDICINE. 

methods ; every practitioner has seen primary sores cured by simple cool- 
ing treatment." 

Notwithstanding all that has been clone to illustrate the pathology and 
treatment of syphilis, it must be confessed that these subjects are still in- 
volved in much difficulty and doubt. A fact so incontestable, and so 
much to be regretted, makes it the imperative duty of every clinical lec- 
turer to contribute whatever materials his experience may supply in elu- 
cidation of questions so important. For this reason, I have been induced 
to lay before you these observations on detached points of interest con- 
nected with the venereal disease. I shall, therefore, beg leave to direct 
your attention at present to the case of a woman, lately admitted into our 
wards, labouring under syphilitic iritis. From the history of her symp- 
toms we learned, that, after a primary venereal affection, she got pains 
principally affecting the joints of the upper extremities, and aggravated at 
night. About a fortnight after admission, she was attacked with papular 
eruption and syphilitic iritis. I beg you will recollect the character and 
order of this woman's symptoms ; at first, she would not admit the ex- 
istence of a venereal taint, stating that her pains were only rheumatic, and 
that she knew no cause for them, except cold. Now, in her case, the 
arthritic affection was seated chiefly in the smaller joints ; one of her 
wrists, and the hand and finger-joints, were swollen, tender, and painful, 
and, at the first glance, had a very strong resemblance to the hand of a 
person labouring under rheumatic arthritis. It is generally believed that 
pains of a syphilitic character occupy chiefly the shafts and ends of the 
long bones ; but in this instance we find that syphilitic inflammation may 
give rise to swelling, tenderness, and pain of the small joints, correspond- 
ing in many points with what has been regarded as rheumatic inflamma- 
tion. We have another case of syphilitic inflammation of the synovial 
membrane and joints in a young woman in the small wards ; but in this 
case, the larger joints are chiefly affected. Tt is absurd to suppose when 
a general disease like syphilis produces pains and inflammatory swellings, 
that they should be always limited to the long bones or their periosteum, 
for we find many instances in which the synovial membranes are also 
engaged. A point worthy of notice in this case is the manner in which 
the iritis appeared. We were treating the woman for the pains I have 
just alluded to, when she was attacked with iritis in a very insidious 
manner. There was scarcely any pain over the orbit, vision was but 
slightly impaired, there was no remarkable alteration in the state of the 
pupil ; in fact, with the exception of some intolerance of light, and some 
conjunctival redness, there was scarcely any thing to indicate the occur- 
rence of iritis. But whenever a person suspected to labour under syphilis 
gets inflammation, particularly if limited to one eye, no matter whether it 
commences in the internal or external tissues, you should watchit closely, 
for the chances are, that it will prove syphilitic ophthalmia, endangering 
vision. And such was the result in this case ; for in four or five days 
the woman exhibited symptoms of decided iritis. It has been very pro- 
perly remarked, that the name syphilitic iritis is calculated to mislead : 
for the iris, in many cases, is not the part principally or primarily attacked ; 
and, in some instances, it appears to escape entirely, although the vision 
is lost. Syphilitic ophthalmia appears a better name for this affection. 

There is scarcely any disease which occasionally proves so insidious in 
its approach as syphilitic iritis, nor is there any form of internal inflamma- 



SYPHILIS. 313 

tion more variable in its progress, degree, or intensity. Sometimes it com- 
mences internally, attacking, in the first instance, the tissues of the iris and 
the adjoining parts, proceeding in its course with remarkable intensity, and 
destroying vision completely, if not arrested at once. In such cases it is 
accompanied by severe pain, intolerance of light, lachrymation, and in- 
creased vascularity of the sclerotic, so that no one can mistake it; but, at 
other times its approach is so insidious, and its progress so slow and pain- 
less, that vision of one eye is lost before the patient is aware of it. The 
iris is then seldom engaged until a late period of the disease ; and the slow 
inflammation, by which vision is ultimately destroyed, commences in the 
deep-seated tissues of the eye. In many cases, as in that now before us, 
it takes a contrary direction, commencing in the external parts of the organ, 
and being usually ushered in by conjunctivitis, apparently simple and pro- 
duced by cold. Hence, you perceive, there is a great variety as to the 
mode of origin, progress, and intensity of syphilitic ophthalmia, and from 
this you will infer that there must be some diversity in the treatment. The 
physician is to be chiefly guided by the intensity with which it attacks the 
eye, and hence the treatment which would be proper for one case would 
be wholly unfit for another. I am anxious to advert to this matter, as I 
think we did not treat the case of this woman as we ought to have done, 
had we considered its nature more attentively. If syphilitic ophthalmia 
be of an intense character, attacking the iris and lens at once, and threat- 
ening to destroy vision in a few days, the activity of our treatment must 
be proportionate to the imminence of the danger; we must bleed, leech, 
and give calomel and opium in large doses, say ten grains twice or three 
times a-day, and must continue its administration until the mouth is affected. 
In this instance, a disease that would destroy vision in three or four days, 
is cured in the same space of time, and the activity of our treatment is 
adapted to meet the intense and rapid character of the ophthalmia. We 
produce full salivation in as short a time as possible, and apply the extract 
of belladonna to the eyelids, to keep the pupil from contracting. In sy- 
philitic iritis there are many shades of intensity, and the treatment must 
correspond with the existing symptoms. Now, if the disease be of a chronic 
nature, and has advanced slowly, it must be made to recede slowly. You 
should endeavour to remove it by the gradual ingestion of mercury, aided 
by the usual local means. In the former case you have only three or four 
days for action, in the latter, you have as many weeks. Hence, I think, 
we were too precipitate in our treatment of this woman. Her disease came 
on slowly, and without violent or urgent symptoms, consequently we ought 
to have treated her mildly, giving small doses of calomel or blue pill, so 
as to bring the system gradually under the influence of mercury. Eut we 
salivated her at once, and the consequence was, that although she improved 
at first, the disease became afterwards exacerbated. Had salivation been 
gradually superinduced, the relief obtained would have been less speedy, 
but more certain and permanent. 

You will, therefore, whether you treat syphilitic iritis or syphilitic pains 
and periostitis, or sore throat, or eruption, be guided by the character and 
progress of the symptoms. If the disease has come on gradually — if it be 
mild or chronic in its nature, and no vital part threatened — you may take 
time and proceed gradually in mercurializing your patient. But where 
the vitality of any organ or part is endangered, you must act with prompt- 
itude, and throw in mercury, as it is termed, at once. Thus, where sy- 



314 CLINICAL MEDICINE. 

philitie ophthalmia attacks the eye in such a manner as to be likely to de- 
stroy vision in a few days, it will be necessary for you to give 5 or 10 
grain doses of calomel three times a-day : and the same line of practice 
will be required when periostitis attacks the orbit, particularly the thin 
plate of bone between the eye and the brain, or when it fixes itself in the 
internal table of the cranium, and threatens the dura mater. 

I may observe here that a consideration of the nature of those tissues, 
in which scrofula is most commonly developed, will give you much infor- 
mation with respect to the administration of mercury in venereal affections, 
and the energy with which this agent is to be employed on various occa- 
sions. The vitality of the white tissues is low, and their inflammatory af- 
fections of a more subacute and chronic character ; and hence not demand- 
ing such energetic treatment as where tissues of a higher order are attacked. 
This you may lay down as a general rule. But there are some exceptions, 
as in the case of an organ composed of various tissues, as the eye; or 
when it attacks purely albuminous tissues in a very acute and intense form. 
In general, the vitality of periosteum and bone is low, and -so is that of 
most of the tissues of the eye ; and whenever you have to treat inflamma- 
tions of such parts, you should not expect to be able to produce any sud- 
den change, for parts of this description require a considerable time for the 
restoration of their healthy functions. Hence, in the majority of cases, 
periostitis and syphilitic ophthalmia, with the exceptions already alluded 
to, are to be removed by a mild alterative treatment, by small doses of 
mercury and gentle frictions, so that some weeks shall elapse before the 
mouth is affected. Nor should you attempt to bring on full salivation : 
touch the gums slightly, and keep them in that state for some time, exhibit- 
ing as much mercury as will just keep its influence in the system. 

I have already devoted some lectures to the consideration of periostitis, 
and it is unnecessary to refer to it again ; but I may observe, that you 
w r ill require considerable discrimination to determine in some cases whether 
the affection you are about to treat is syphilitic or not. You will find 
many examples of periostitic inflammation depending wholly on a scro- 
fulous taint in the constitution ; for scrofulous inflammation is often fugitive, 
and attacks the periosteum before it fixes in the bones. You may also have 
periostitis from rheumatism, or from gout ; but one of the most common 
causes of periostitis, in persons not labouring under syphilis, is connected 
with the secondary effects of mercury on the constitution. Persons who 
have taken mercury for any disease, no matter whether it be pneumonia, 
pleuritis, or hepatitis, are afterwards subject to periostitic inflammation, 
and this liability continues not for months, but even years. Indeed, 
periostitis is one of the most common effects of mercurialization, particu- 
larly if the patient be exposed to cold while taking mercury. In the 
course of one, two, three, five, or even a greater number of years, expo- 
sure to cold, a blow, and other apparently trivial causes, will give rise to 
periostitis in some individuals. I am at present attending, with Mr. 
Crampton and Mr. Cusack, a gentleman labouring under periostitis of 
the tibia and cranium ; and on inquiring into the history of his case, we 
found that it is nearly nine years since he was salivated. I have also 
witnessed a very severe case of periostitis affecting the shafts of both 
tibiae in a lady who took mercury about five or six years ago for supposed 
hepatitis. One of the most remarkable cases of periostitis after mercury 
which have ever come under my notice, I have recently witnessed in the 
person of a gentleman who was for some years surgeon to the British 



SYPHILIS. 315 

Envoy to Mexico. In that country, raised nearly 12,000 feet above the 
level of the sea, and exposed at once to sharp winds, and a burning 
tropical sun, fevers of an intense character often prevail. Some time 
after his arrival, this gentleman was attacked with fever, for which he 
was fully salivated. He caught cold during his convalescence, and was 
attacked with periostitis, for which he took mercury again with relief. 
Next year he caught cold again, was again attacked with periostitis, and 
cured by mercury, as before. The year after, the same series of accidents 
was repeated. I forget how many successive attacks he had, each origi- 
nating from cold, and each, like the former, removed by mercury. At 
length the mercury seemed to lose its power over the disease, and was 
no longer capable of relieving it. He returned to this country with the 
view of improving his health by change of air, and presented a most 
extraordinary spectacle. The periostitis had chiefly fixed itself in the 
cranium, which it had altered so as to have no longer any resemblance to 
the human skull. When I saw him, a considerable portion of the peri- 
cranium and bones of the head had been affected with periostitis for three 
years, without any intermission. His skull would have defied the scrutiny 
of Gall and Spurzheim, for its shape was the most extraordinary I ever 
witnessed. He was in the habit of taking large quantities of opium to 
procure some alleviation of his sufferings, and was restless to such a 
degree that he was frequently for fifteen or twenty nights together without 
an hour's sleep. Altogether he was in the most pitiable state ; and seldom 
got any relief until the attacks were wearing off, when he enjoyed some 
brief intervals of repose. Some fifteen or twenty years ago, when the 
subject of the treatment of syphilis was warmly canvassed, it was asserted 
by the mercurialists that mercury never gave rise to nodes or periostitis, 
unless where there existed a syphilitic taint in the constitution. Now I 
can attest from manifold experience that this is not true. The gentleman 
whose case I have related had never been affected with syphilis. But 
there is no necessity of insisting on this point. Every practical physician 
knows that mercury may and does give rise to a train of symptoms bearing 
some analogy to those of secondary syphilis. Thus, after the use of mer- 
cury, a patient may be attacked with feverishness, pains in the bones, 
nodes, sore throat, and an eruption, to which the name mercurial eczema 
has been given. Here you perceive we have a remarkable analogy 
between the diseases produced by mercury and syphilis. Mercury, when 
exhibited improperly, may produce all the affections I have enumerated, 
and in addition to these, caries of the bones, particularly of the nose and 
palate. It is well known that some active remedies have a tendency to 
produce diseases somewhat analogous to those they are known to cure. 
This is frequently observed with respect to mercury, belladonna, strychnia, 
quinine, hydriodate of potass, and some other powerful medicinal agents. 
In fact, it is hard to expect that a remedy will cure a disease affecting a 
certain tissue or tissues, unless it has some specific effect on such tissues ; 
and in this point of view we have an example of the " similia similibus 
curantur" of the homoeopathists. 

Mercurial ostitis of the head is a very common form of disease : its 
more usual seats are the frontal and parietal bone ; but it is sometimes 
observed also on the other bones of the skull. In general, the inflamma- 
tion affects the external table of the bone, and is then easily recognised 
from the tenderness and swelling of the corresponding portions of the 



316 CLINICAL MEDICINE. 

scalp. Sometimes, however, the inflammation commences in the internal 
table of the skull, and where this occurs, the disease wears a much more 
alarming aspect, for it is then apt to implicate the dura mater and subja- 
cent portion of the brain. In such cases, the true nature of the complaint 
is not unfrequently overlooked, or mistaken for some other disease causing 
headache. This is a very serious and fatal error: for unless the physi- 
cian is aware of the real nature of the malady he has here to contend with, 
he will seldom adopt proper measures, and the patient will fall a sacrifice. 
Such cases are indeed obscure, but we may in general make out their true 
nature by a careful attention to their history. Thus, if severe nocturnal 
headaches arise in a person who has ostitis in other bones, and if the pain 
darts from some fixed point, then, although all external tenderness be 
wanting, we may safely conclude that the cerebral affection originates in 
ostitis of the cranium. In investigating such cases, I have derived much 
advantage from percussion. I place the back of one finger on the patient's 
head, and tap it smartly with the fingers*of the other hand. If internal 
ostitis be present, every tap excites a peculiar internal pain in the part 
affected, which pain is the greater the nearer the part percussed is to the 
seat of the disease. 

You have seen in our wards several men complaining of very agonizing 
headache without any external tenderness ; and you have witnessed in 
these cases the failure of the common means for relieving pain in the head, 
and the success which followed the adoption of a treatment founded on 
a true diagnosis of the disease. This headache, yielding to no other 
species in severity, deprives the patient altogether of rest — occasionally 
occupying chiefly one side of the head — and most severe at certain hours, 
is not unfrequently mistaken for nervous hemicrania, and treated with 
iron ! When ostitis occupies the external table of the cranium, it seldom 
strikes inwards, so as to engage the internal, and disorder the brain. That 
it does so sometimes appears from several cases ; among the rest, that of 
Mary Wilkinson, admitted into our ward on the 21st of October. In her 
the scalp was excessively tender, and felt in one part thickened and 
boggy. There was dilatation and increased pulsation of the external 
arteries supplying that side of the scalp. On the 27th, the headache 
increased, and she fell into a state of profound coma, with dilated pupils 
insensible to the light ; the extremities were cold, and pulse scarcely per- 
ceptible. Luckily, while in this state, the mercury previously adminis- 
tered began, next day to affect her mouth, and, aided by large doses of 
calomel, and powerful blistering, soon restored her. Such a recovery 
very seldom takes place. Ostitis is also very dangerous when it occupies 
the orbital and contiguous portions of the frontal bone. It is very obscure 
when seated at the base of the scull. 

Mercurial ostitis is a very common occurrence in the cervical vertebrae, 
but comparatively rare in the dorsal. In the lumbar it becomes again 
more frequent, but not so much so as in the cervical. I have, however, 
seen some cases where the dorsal vertebra? appeared to be almost all 
engaged in the disease, and where, consequently, the greatest agony was 
experienced on their being touched or moved. Pathologists have not yet 
paid sufficient attention to the species of neuralgia which is occasioned by 
inflammation of the nerves or their sheaths, spreading from the surface of 
the bones through which they pass. 

Nothing is more certain than the fact, that in many, the abuse or even 



SYPHILIS. 317 

the use of mercury renders the constitution disposed to ostitis on future 
occasions, when cold and damp act on the body, especially if fatigued 
by exercise, or exhausted by dissipation. This ostitis is consequently 
called mercurial : but this name must not mislead us ; for, strange as it 
may appear, the disease often yields readily to mercury — a mode of treat- 
ment generally effectual for the moment, but attended with the obvious 
disadvantage, that it leaves the patient more liable than ever to future and 
severer relapses, which will at last refuse to yield to mercury. 



LECTURE XXX. 

Difference of opinion respecting the use of mercury in the venereal disease — The question 
discussed, Is it possible to cure secondary symptoms without mercury 1 — Chancres — Abuse 
of Mercury — General treatment m Syphilis — Other poisons capable of producing an eruption 
similar to syphilitic — Concluding remarks : on chancre ; mode of applying caustic in venereal 
sores, &c. 

In one of my first lectures I stated that, notwithstanding the host of facts 
bearing on the question of the non-mercurial treatment of primary and 
secondary syphilis, there is still much difference of opinion amongst men 
of the highest rank in the profession. One good has resulted from the 
statements put forward by the army medical practitioners, namely, that 
mercury is no longer abused in the empirical and barbarous manner fol- 
lowed by our predecessors. Few, if any, at the present day, will be 
found to enter upon long and exhausting courses of mercury, for slight 
chancres or sores, in persons of delicate or scrofulous constitutions ; and 
I believe the opinion is growing stronger and more general every day, 
that when primary symptoms occur, although mercury be omitted, or 
merely used as an alterative, the disease may be successfully treated. 
Let me, however, be understood in this matter. I make this statement in 
reference to those cases only in which the disease is treated from the com- 
mencement, and not allowed to go on unchecked for days or even weeks. 
I have already brought forward evidence to prove, that when genuine 
chancre is treated properly from the beginning, it may be cured without 
mercury. There must have been several cases of true chancre among 
Dr. Roe's patients, and yet of the entire number there was only a single 
case of secondary venereal, and that in a patient broken down in health 
and labouring under bubo for a considerable time before admission. 

But you will ask — Is it possible to cure secondary symptoms without 
mercury ? If you are to believe some authors, you cannot. According 
to their views of the case, a patient labouring under secondary symptoms, 
if treated without mercury, may get well for a while, but the disease will 
return again and again until it breaks up his health. All I can say on the 
point in question is this, that I have seen several cases which were pro- 
nounced secondary syphilis get completely well without mercury. About 
ten or twelve years ago there w T as a case of secondary syphilis in this 
hospital, which I undertook to treat without mercury. It was a case of 
well-marked papular disease, which had made its appearance about six 
weeks after the primary sore ; and, to remove all doubts on the subject, I 
showed the man to the late Mr. Hewson — a gentleman justly esteemed 



318 CLINICAL MEDICINE. 

for his accurate and extensive knowledge of the venereal disease. He 
pronounced it at once a case of true syphilis, and added that it could not 
be cured without mercury. As there was no urgent reason for the exhi- 
bition of mercury, I thought the matter worthy of experiment, and treated 
the man with purgatives and antimonials, followed by vegetable altera- 
tives and nitric acid. I did so and succeeded in effecting a perfect cure. 
I kept the man afterwards under surveillance, to see if a relapse would 
occur. He never had a return of the disease, and Mr. Hewson was quite 
struck with the result, as he had no conception that the patient could be 
cured without mercury. Indeed this was the general opinion, the other 
surgeons of the Meath Hospital having arrived at the same conclusion. 
The case made a very strong impression on my mind, and, connected 
with others having a similar result, has convinced me, that there is some 
truth in the statements of those authors who say that syphilis can be cured 
without the mineral. On the other hand, I must confess that there are 
some cases which answer the description given by Mr. Colles, and which 
cannot be cured without bringing the patient under the influence of mer- 
cury. Thus a very fine healthy young man, whom I attended some 
years ago, put himself under my care for chancre, after having neglected 
the disease for three weeks or more. Now w T hen a case of this kind, 
which has been allowed to run on unchecked, comes before you, you 
should not be too sanguine, or think that your patient will be perfectly 
safe under the non-mercurial treatment ; for where chancres are neglected, 
secondary symptoms are very apt to occur. I treated him with purgatives 
antimonials, rest, and low diet. He had no buboes, and got quickly well ; 
but about five or six weeks afterwards he was seized with symptoms of 
fever, accompanied by acute pains of the joints, and two days afterwards 
got venereal eruption and sore throat. He had in fact all the symptoms 
of venereal exanthematous fever, and his skin became covered with 
blotches — the character of which could not be mistaken. They were 
neither papulae, pustules, nor tubercles, but true venereal blotches, termi- 
nating in scaly scurf. I gave him tartar emetic, followed by vegetable 
alteratives, and he got better. He continued well for about a fortnight 
or three weeks, and then another eruption broke out, attended with pains 
and fever as before. The non-mercurial plan was tried again, and was 
again followed by the same apparent success; the eruption faded, and 
his throat got better. He then took lodgings in the country, for the be- 
nefit of change of air, but while there was attacked a third time more 
severely than before. He had fever, eruption, and sore throat, and in ad- 
dition to these, periostitis and nodes; he was also becoming weak and 
emaciated. Under these circumstances I prescribed calomel and mercu- 
rial ointment, until his mouth became sore. His symptoms all gradually 
disappeared, and he has had no return of the disease. In this gentleman 
the greatest attention was paid to diet, confinement to the house, and 
every circumstance which could favour the success of the non-mercurial 
plan. The patient's constitution was excellent, and free from any scro- 
fulous taint, and yet the syphilitic poison seemed to be rapidly undermining 
his strength, and the disease acquired fresh force from time instead of 
growing less violent ; in fact, its progress was so alarming that mercury 
could be no longer with safety withheld. A very moderate course of 
mercury, managed so as to keep his mouth tender for six weeks, thoroughly 
and permanently cured him. 



SYPHILIS. 319 

Now to what conclusion does all this lead ? simply to. this, and I be- 
lieve it is the conclusion to which all rational men have come, that al- 
though there are many cases of syphilis, which can be cured without 
mercury, there are others in which its employment is indispensable. 

In the two cases, which I have just related, the results were very dis- 
similar. In the first, a case which had been pronounced distinctly vene- 
real by some of our most distinguished surgeons, and not to be cured 
without mercury, the non-mercurial treatment proved quite efficacious ; 
the man was readily cured, and had no return of his disease. The other 
case, which you would have regarded as most favourably circumstanced 
for getting well without mercury, had quite an opposite result ; the dis- 
ease returned again and again, and did not yield completely until the sys- 
tem had been brought under the mercurial influence. Hence you per- 
ceive the necessity of avoiding extreme opinions, or coming to any gene- 
ral conclusions as to the treatment of syphilis. 

The inference which my experience has led me to draw on the subject 
is, that many cases of syphilis — indeed a great majority of cases of pri- 
mary sores — may be cured without mercury, if treated at once and pro- 
perly. 

Alter chancres have existed for some time, the chances of secondary 
symptoms are greatly increased, and mercury in such cases will be often 
required ; but it should be used with caution, and moderately. Were I 
to speak for myself, I would say, that, as a general rule, I prefer the non- 
mercurial plan in the treatment of primary chancres, particularly if seen 
at the commencement, and where they appear in persons of a delicate 
and scrofulous habit. I think at least you will not be wrong in giving 
many cases of chancre a trial, and see whether you cure them without 
mercury. If secondary symptoms appear, you have still a resource in 
mercury; the patient's constitution is unimpaired, and the disease is still 
amenable to treatment. If you treat your patient properly, he has many 
chances in his favour ; and if he gets secondary symptoms, mercury will 
still act favourably on his system. The rational practitioner is neither a 
mercurialist nor a non-mercurialist ; he acts according to the state and 
peculiar exigencies of each case, and selects his plan of treatment accord- 
ing to the form, condition, aad duration of the disease, as well as the con- 
stitution of the patient. If the chancres be of a mild, and what may be 
termed indolent character, the application of nitrate of silver at an early 
period, combined with rest, low diet, aperients, and, if necessary, vege- 
table alteratives, will complete the cure. If attended with inflammatory 
symptoms, a vigorous adoption of the antiphlogistic plan will be indis- 
pensable, and the use of caustic applications must be deferred until the 
symptoms of inflammatory action are abated. 

Whenever you get a chancre in its commencing period to treat, try the 
antiphlogistic and non-mercurial plans, and, if your patient improves, per- 
severe ; but, if there be no amendment, you may have recourse to the 
cautious exhibition of mercury. I say cautious, for in some constitutions 
you cannot be too careful in the administration of this remedy. The con- 
sequences which have followed from the injudicious use of mercury have 
been often and strongly depicted, but not in colours too strong for truth ; 
the lamentable results which have attended its abuse rank among the 
greatest opprobria of medicine. 

In Johnson's General History of Pyrates — a most curious book, pub- 



320 CLINICAL MEDICINE. 

lished in 1725, and from which Sir Walter Scott has borrowed some of 
his best traits of nautical character — we find a passage proving the abuses 
of mercury were great at that period, and that even then facts were not 
wanting to show that this mineral was not indispensably necessary for the 
cure of syphilis. In the following passage I have preserved the spelling 
of the original. Talking of the Brazils our author remarks, — M The 
Generality of both sexes are touched with venereal taints, without so 
much as one surgeon among them or any one skilled in Physick to cure 
or palliate the progressive mischief. The only person pretending that 
way is an Irish Father or Priest, whose knowledge is all comprehended 
in the virtues of two or three simples, and those, with the salubrity of the 
air and temperance, is what they depend upon for subduing the worst of 
malignity ; and it may not be unworthy to notice, that though few are 
exempted from the misfortune of a running, eruption, or the like, yet I 
could hear of none precipitated into those deplorable circumstances we 
see common in unskilful mercurial processes." 

Who can read, without shuddering, the long detail of misery inflicted 
on unfortunate venereal patients in the time of our predecessors ? the ex- 
hausting salivations — the inveterate nodes — the frightful caries and slough- 
ing — the emaciation — the hectic — the rapid or lingering, but ever fatal 
phthisis. Hundreds of victims, w T hose slight primary symptoms might 
have been successfully treated without a single grain of mercury, have 
had their constitutions gradually broken down, until at length scrofula 
became fully developed, and was quickly followed by its attendant, tuber- 
cular consumption. 

Thanks to the exertions and labours of the army surgeons, w T e no longer 
behold the same indiscriminate exhibition of mercury, or the same wicked 
tampering with human life. The evils which have flowed from the abuse 
of mercury are greatly diminished, but still not sufficiently exploded from 
British practice. Notwithstanding all that has been said and done, a good 
deal still remains to be accomplished, before the treatment of syphilis can 
be said to be placed on a solid and rational basis. I am not among those 
who contend that you should never use mercury. On the contrary, I 
think there are cases in w T hich you can employ it to great advantage — in 
fact, where its employment is indispensable. But I would have you 
always to act with caution. In treating cases of primary or secondary 
symptoms, which have existed for some time, and where the patient has 
been taking mercury, it is hard to unravel the perplexities which surround 
the case, and ascertain whether the mercury has been properly adminis- 
tered or not. 

WTiere a patient labouring under syphilis has been salivated without 
being improved, one of two things must be inferred — either that the 
mineral has had no effect on the disease, or that it has had an injurious 
effect on the constitution. The great point to arrive at in the treatment 
of syphilis is to make the mercury act on the disease, and not on the con- 
stitution. This I have often endeavoured to impress on my class. I will 
venture to say, that I would engage to give a patient labouring under 
primary symptoms any quantity of mercury, without producing a favour- 
able effect on the disease, or doing him any good : I would engage to 
salivate a man affected with sore throat, and yet leave him as bad, 
or even worse than ever. I have witnessed this occurrence over and 
and have laid it down to myself as a proposition, — that 



SYPHILIS. 321 

venereal may be treated with mercury, to the fullest extent, without being 
cured. 

Syphilis and mercury are not like two opposite forces — not like an acid 
and an alkali — so that by putting them together you are sure to neutralize 
them. No. It is a melancholy fact, but true, that the constitution may 
be impregnated with both at the same time. Some time ago, a gentle- 
man's coachman was admitted into Sir Patrick Dun's Hospital. He got 
primary symptoms, for which he took mercury ; but being of active habits, 
and unwilling to quit his employment, he remained with his master, whom 
he was frequently obliged to attend at night. In this way, he was often 
exposed to wet and cold, and used to take whiskey, with a view of pro- 
tecting himself. The consequence was, that eight weeks afterwards he 
came into Sir P. Dun's Hospital with his mouth sore and fully salivated, 
but labouring under bad sore throat and extensive eruption. In adverting 
to his case before the class, I said, " This appears to be a very bad spe- 
cimen of the mercurial treatment, but you are not to conclude from what 
you see that mercury will not cure the disease. We will keep him in 
hospital ; give him mild aperients, light nutritious diet, and sarsaparilla ; 
and when we have removed the bad effects of mercury on his constitution, 
we will proceed to administer it again, but in such a way as to act on the 
disease, and not on his general health." About three or four weeks 
afterwards, the man was so much improved, that we were able to put him 
again under a mild course of mercury, and succeeded in eradicating every 
symptom of disease. Although a patient has got worse under the use of 
mercury, you should not conclude that it is incapable of curing the dis- 
ease : it may have been administered improperly ; and under such cir- 
cumstances, I tell you again, no good can be expected from it. In such 
cases, the morbid action of mercury must be allowed to pass off completely 
before we have recourse to the mineral again ; and if this be done with 
circumspection and care, the best and most favourable results may be ex- 
pected. I agree perfectly with the judicious observations put forward on 
this subject by Dr. Lendrick, and I would strongly recommend every gen- 
tleman present to read his excellent paper, published in the 32(1 number 
of the Dublin Medical Journal. As in many acute diseases, particularly 
those of the class Exanthemata, so in syphilis you may have great variety 
in the symptoms. Some of them will be faintly shadowed out, or alto- 
gether absent ; while others may manifest a remarkable prominence. In 
measles you may have the eruption without the catarrhal symptoms ; in 
scarlatina, the sore throat without the eruption, or, what is still more 
curious, the desquamation and dropsy without any apparent preceding 
symptoms. So also in syphilis, in which you may have chancre without 
bubo, sore throat without eruption, or periostitis without any well-marked 
appearance of the symptoms which usually precede it in the order of time. 
You are not to expect that the disease will always appear in the form laid 
down by the great John Hunter, or that the symptoms will pursue the 
precise order marked out by him. As in acute disease, where not merely 
a single symptom, but even whole groups of symptoms, may be absent, 
so in many forms of chronic disease, some of the characteristic marks will 
be occasionally wanting. There is much variety in the forms, intensity, 
complexion, and duration of chronic diseases, and particularly with regard 
to those which arise from animal poisons. Scarlatina, typhus, measles, 
and small-pox, produce very different impressions on different constitu- 
22 



322 CLINICAL MEDICINE. 

tions, operating on some mildly and favourably, on others with extreme 
intensity. The same variety is seen in the constitutional symptoms pro- 
duced by syphilis : in some they are slight and chronic, in others acute 
and violent. In fact, syphilis is so variable a disease, that every reflect- 
ing and experienced observer will be led to the conclusion, that it must 
require a mixed and varied treatment, and that its treatment cannot be 
based on any general code of laws as laid dow T n by mercurialists or non- 
mercurialists. By acting in this way, you will avoid both extremes, and 
pursue a wiser and a better course. 

There is another point to which I shall direct your attention before I 
conclude. It is of great importance in the treatment of venereal affections 
to bear in mind that there are other poisons capable of producing an erup- 
tion similar to the syphilitic. 

In a lecture published last year, I endeavoured to show that in some 
deranged stages of the constitution, the human body is capable of gene- 
rating an animal poison within itself, one of the characters of which is a 
more or less general cutaneous eruption. I have also shown that deranged 
local action of a part of the body may be followed by inflammation and 
the formation of matter capable of infecting the whole constitution. I have 
more than once, while going round the wards, been struck with the ap- 
pearance of a sore of this description, and on stripping the patient found 
some of Mr. Colles's pustules on the skin. 

Some time ago a young man came into this hospital with gonorrhoea 
and phymosis ; he was unable to draw back the prepuce, and the conse- 
quence was, that the extensively ulcerated glans lay constantly bathed in 
gonorrhceal matter. Shortly after admission his skin became covered with 
an extensive papular or papulo-pustular eruption, which was looked upon 
by many as true venereal. He also became emaciated, and sore throat, 
very closely resembling syphilitic sore throat, made its appearance. The 
prepuce having been divided, he was treated with small doses of arsenic, 
mild nutritious diet, rest, and lotions of sulphate of zinc, and recovered 
completely. A case still more curious occurred some time since. A gen- 
tleman, one of the pupils, .cut his finger while dissecting. The wound 
was followed some time after by a suppurating tumour resembling a whit- 
low, which lasted for a long time, and finally generated a poison, which 
produced sore throat and a cutaneous eruption, the latter of such an ob- 
stinate character that, after trying many remedies, he was obliged to have 
recourse to mercury. These facts, coupled with others of a similar ten- 
dency, show that venereal symptoms present a considerable variety as to 
their number, order, form, duration, and curability by mercury, conse- 
quently it often becomes a matter of difficulty to distinguish Ihe true 
nature of the disease, and separate it from other influences by which it 
may be modified. Hence, too, the caution with which we should pro- 
ceed to subject a patient to a course of mercury. 

One word now with respect to the treatment of chancres. I think it is 
a matter of the utmost importance to the medical man, as well as to the 
patient, that chancres should be seen and treated in the very commence- 
ment, that is from two to four or six days after their appearance. Like 
the effects of many animal poisons, they are at first merely a local disease, 
and seldom affect the constitution, until they have been for some time in 
existence. In the beginning they produce local irritation, but if neglected 
may give rise to constitutional affection. Hence the importance of being 



SYPHILIS. 323 

treated from the commencement, and to this circumstance I attribute the 
chief part of the success that attended Dr. Roe's practice, and the rare oc- 
currence of secondary symptoms among the men intrusted to his care. I 
feel convinced that chancre, if seen shortly after its appearance, may, in 
eight cases out of ten, be treated safely and successfully without a single 
grain of mercury. 

There are very few animal poisons which may not be arrested and de- 
stroyed at the point of inoculation, if treated properly. I feel fully con- 
vinced, that if you were to take a vaccine vesicle, and destroy it with ni- 
trate of silver shortly after it has made its appearance, the virus w T ould not 
affect the constitution, and that the child would not be protected from the 
danger of infection from small-pox. Burn the whole vesicle, it will heal 
like any other part, and the child will not be safe from infection. You 
may smother the disease while it is merely local, and before the constitu- 
tion is affected. Such at least appears to be the case with many animal 
poisons, and in particular with regard to the venereal. 

As it is extremely desirable to arrest the local progress of chancre, many 
methods of accomplishing this object have been devised, among which 
none appear more certain or efficacious than the application of escharotics. 
If the disease be detected in its very early stage before the matrix pimple 
has burst, or immediately after that event, the destruction of the local dis- 
ease proves, in the great majority of cases, a perfect protection against con- 
stitutional sequelae When the chancrous ulceration has once commenced, 
and has been allowed to remain unchecked for one, or two, or three days, 
it is still more desirable to extirpate the local malady, and the result will 
generally be successful. The chance of protecting the constitution dimi- 
nishes in proportion as the operation is deferred, but we want data to 
enable us to calculate at what period it ceases to be at all protective ; that 
period probably varies in different cases. 

Be this as it may, it is an essential point in practice to get rid of the 
primary sore as speedily as possible ; how it is best to effect this object is 
a subject which requires a few remarks. The usual mode of treating small 
sores, whose diameter does not exceed that of a common stick of lunar 
caustic, is to apply the latter in substance, so as to produce a small eschar 
of the required size ; this method seldom fails, but is attended with the 
disadvantage that it often gives rise to sympathetic bubo, as the caustic is 
not unfrequently used with too little caution. I have accordingly given 
up the use of the solid caustic, except where the pimple or ulcer is very 
small, requiring merely a slight touch of the pointed pencil. Many prac- 
titioners lean too heavy on the pencil during its application, and keep it 
too long applied, and consequently the resulting inflammation and eschar 
are far more considerable than are necessary, and also more likely to pro- 
duce bubo. 

When the sore is so large that the diameter of its surface equals or nearly 
equals a line, it is already too extensive for the application of the solid 
caustic without incurring the risk of bubo. Under these circumstances, or, 
a fortiori, when the sore is still larger, I use the following method: — Pro- 
vide yourself with a common- sized, nicely-pointed camel's-hair pencil, 
and a solution of lunar caustic, twenty grains to the ounce. Pour a drop 
or two of this on the cover of a book, or on the table, and dipping the 
brush in a basin of water, cleanse the surface of the sore w r ith it. Dry the 
sore then completely with a piece of lint, and, rinsing the brush, squeeze 



324 CLINICAL MEDICINE. 

out the chief part of the water, and, pointing the brush, you may then dip 
the extreme point of it in the drop of caustic solution, so as to take up the 
smallest possible quantity of fluid, which you may then apply to the centre 
of the sore. When it has done acting, we may readily judge, by the ap- 
pearance of the surface, whether enough has been applied, for the whole 
surface must be whitened ; but it is not, as is usually imagined, proper to 
burn out the edges. It may be necessary to dip the end of the brush in 
the solution, and apply it to the sore a second or even a third time, paus- 
ing to observe the effects of such application. By proceeding thus, we 
destroy the diseased surface, and do not produce any inflammation likely 
to give rise to bubo. 

Some practitioners are much bolder, and use the solid caustic much 
more freely, desiring the patient to keep the part poulticed ; but their 
mode of proceeding is very objectionable. When the solution has been 
properly and cautiously applied, no dressing to the part is required, except 
a bit of lint or charpie. In some cases, it is better to use as an escharotic 
the nitrate of copper, which may be employed in the form of Concentrated 
solution, obtained by allowing the solid salt to deliquesce. Here the 
camel's-hair pencil and the same precautions are required. 

After cauterizing the surface of a chancre, I have frequently applied a 
little of the fur or felt of hat to the ulcer, and directed the patient not to 
remove it, if it adhered to the surface, which it will sometimes do, forming 
a scab that does not drop ofT until the sore is quite healed. Although we 
may not have recourse to applications decidedly escharotic (which is the 
surer way), yet I think the early and diligent use of stimulating lotions of 
lead, sulphate of copper, and sulphate of zinc washes, serve to a certain 
degree to protect the constitution. The fact is, that chancres so treated 
in the very beginning, and thus altered, and caused to assume a healing 
process, cease to be so likely to infect the system either of the individual 
himself, or of females with whom he may have connection. A similar 
remark applies to gonorrhoea; an astringent injection, used several times 
immediately before connection, will for the time, so alter the nature of the 
urethral secretion, that it will cease to be infectious, although it may 
become so in half an hour or an hour afterwards. 



LECTURE XXXI. 

Treatment of syphilis continued — Use and abuse of mercury, with cases — On the causes which 
impede its beneficial action — Corrosive sublimate to be preferred in some cases — Observa- 
tions of authors, &c. 

I have stated, in a former lecture, that you may give mercury for syphilis 
in such an injudicious way, that all the efforts of the medicine are ex- 
pended, not on the disease, which it is meant to cure, but on the consti- 
tution of the patient, which it injures. This proposition, whose truth has 
been long recognised, cannot be impressed too strongly or too clearly on 
your minds; for on accurately comprehending its scope and meaning will 
depend your success in the diagnosis and treatment of difficult cases. 
Nor is this peculiar to mercury when used in the venereal disease, for the 
same mineral may be so mismanaged, in other diseases also, as to produce 



SYPHILIS. 325 

no beneficial effect, although it be the very best remedy that can be adminis- 
tered in them, when judiciously prescribed. Thus, give calomel in con- 
siderable and repeated doses to a dysenteric patient, and allow him at the 
same time to use cold and acid drinks, and a mixed diet with vegetables, 
and you will render the disease worse instead of better, especially if 
the skin be freely exposed to alternations of temperature and cold air. 

Again, when a violent pneumonia has hepatized a considerable portion 
of the lung, no remedy exceeds mercury in value ; but it may, neverthe- 
less, and I regret to say not unfrequently is, given under such circum- 
stances, without the necessary precautions, and consequently rather injures 
than serves the sick man. The same observation applies to mercury 
when ordered in pleurisy or peritonitis, and is remarkably exemplified in 
arthritis and sciatica : in the latter disease, unless proper precautions as 
to temperature and rest are taken when giving calomel, you will be sure 
to salivate without obtaining any relief of suffering. 

If opium be administered without tact, at wrong times, and in wrong 
doses, it often fails to procure sleep, and causes watchfulness, and so it 
is with all our remedies ; they only produce a curative effect when 
properly exhibited. Certain states of the system, too, prevent the kind 
constitutional action of mercury. Suppuration of the liver renders it 
almost impossible to affect the mouth, as has been remarked by Annesley 
and Marshall. When the constitution is eminently scrofulous, mercury 
rapidly gives rise to a new group of bad symptoms, and fails to cure the 
venereal cachexy for which it was given. 

The presence of the scorbutic diathesis — and it often maybe associated 
with syphilis — renders the use of mercury unsafe and even injurious ; 
even in healthy constitutions the favourable influence of mercury on the 
venereal symptoms may be interrupted or destroyed by strong mental 
emotions, excessive fatigue, bodily labour (hence the difficulty of getting 
mercury to act well on day-labourers and artizans, while employed), irre- 
gularity of diet, intemperance, &c. &c. 

In all cases where any of these causes operate on the system, it is 
extremely difficult to prevent the mercury from going astray (as it is 
termed), that is, injuring the constitution without serving the disease. 

The following example proves the truth of this observation, and shows 
that a very great difference of opinion may exist even amongst the most 
determined mercurialists, respecting the propriety of giving and with- 
holding mercury in certain cases. 

Some years ago, I was called to see a young gentleman who had 
recently contracted a chancre. His constitution was perfectly good, and 
I proposed to cure the sore without mercury. To this he would not 
consent, and consequently I thought it right to call in the aid of the family 
medical attendant. He advised the use of mercury, and we prescribed 
five grains of blue pill, three times a-day, after a few days' preparation 
by means of confinement, rest, and low diet. By a mistake on the part 
of the patient's brother, he got five grains of calomel, three times a-day, 
instead of five grains of blue pill. A rapid improvement in the chancre 
took place, and on the fourth day we found the sore nearly healed, but 
the mouth much more affected than we had anticipated. He had then 
taken one drachm of calomel. That evening some young friends came 
to his room, and persuaded him to join them in a supper of oysters, 
punch, &c. In the night a most violent attack of mercurial cholera, with 



326 CLINICAL MEDICINE. 

colic, vomiting, and purging, came on, and reduced him to a state of 
great debility. The mistake, as to the calomel, was now discovered ; and, 
in consultation on the following day, his mouth being very sore, and the 
chancre spreading, it was agreed to use soothing measures, local and con- 
stitutional. At the end of a week, we found the sore on the prepuce per- 
fectly stationary : it seemed neither inclined to spread nor to heal, while 
his mouth was still a little sore, and his breath fetid. My colleague 
now advised the resumption of mercury, which was accordingly used, 
both internally and externally. In about ten days, during which time he 
scrupulously followed our directions, his system was again brought under 
the active influence of mercury, but still the sore was stationary. My 
colleague still wished to go on with the mercury ; I dissented, and another 
consultant was called in. This gentleman, although a mercurialist, 
thought mercury here inapplicable, and w T e therefore left it off. I now 
touched the sore with nitrate of copper, and, applying to its surface some 
felt of hat, a scab was formed, which adhered until the sore completely 
healed. Several years have elapsed, and the patient continues well. 
Here, then, was a case where two mercurialists, of great experience, 
differed as to the expediency of giving mercury. As authorities, they 
might be deemed equal, and yet, at a particular crisis, their opinions were 
diametrically opposed — an occurrence alone explicable on the grounds 
that the principles which guide mercurialists are not so precise and cer- 
tain as they profess them to be. Indeed, on many occasions, I have 
found the greatest discrepancy of opinion between mercurialists as to the 
length of time during which mercury ought to be continued after it has 
caused a primary sore to heal, in the same case one practitioner advising 
a mercurial course twice as long as that recommended by another. Occur- 
rences such as these demonstrate that much still remains to be done in 
this department of medical science, and such errors should teach us all — 
for we all make them — the necessity of acknowledging, that, as yet, our 
opinions upon this subject are based upon no very firm grounds ; and 
that consequently we should be tolerant of the opinions of others when 
they differ from us either in theory or practice. Toleration, such as I 
have recommended, is but too rare, and manyseem incapable of arguing 
or lecturing calmly and philosophically on the subject of the treatment of 
venereal. Now in the case above related, it appears to me that the mer- 
curialists forgot some of the rules laid down by the advocates of mercury. 
Let us reconsider it for a moment : a venereal sore is rapidly healing 
under the influence of fifteen grains of calomel daily ; had a proper diet 
been observed, another day would have completely healed the sore, but 
unluckily the patient commits a gross indiscretion of diet, and, suddenly 
after that, the sore spreads beyond its original dimensions, and continues 
obstinately to refuse to heal again in spite of the patient's ill-advised per- 
severance in the further use of mercury. Under these or similar circum- 
stances, the rule laid down by Mathias becomes applicable, viz., that 
when a sore becomes stationary (having been previously healing) or gets 
worse under the use of mercury, it is injurious to exhibit it any longer ; 
it must be laid aside, until those causes which deranged the constitution, 
and impeded the proper action of the mercury, have ceased to exist. 
But to prove still further that the most strenuous supporters of the mer- 
curial system are liable to errors — to grievous errors — I shall give you the 
following case, on the accuracy of whose particulars you may implicitly 



SYPHILIS. 327 

rely. The practitioner who conducted the treatment is considered to be 
a most skilful mercurialist, and most experienced in the management of 
syphilis. When the rules that should guide us in the exhibition of mer- 
cury prove so fallacious in such hands, how much more likely are they to 
fail with the young and inexperienced ! 

Mr. , a strong, healthy young man, got a small pimple and sore on 

penis after connection, 25th Nov. 1836. He consulted a medical friend 
on the very day the pimple came out: he was assured that it was not 
venereal, and was desired to return on the 5th day ; then also the same 
opinion was repeated. Suspicious of its accuracy he went to another prac- 
titioner, who put him on alterative doses of mercury ; Plummer's pill was 
continued for ten days without any soreness of moulh ; it was then dis- 
continued, as primary symptoms had healed. He remained quite well 
until February, 1837, in the middle of which month three or four large 
tubercular pimples slowly formed and suppurated on the scalp, neck, and 
face. His general health, however, appeared quite good. On the 2d of 
March, 1837, throat felt a little sore, and he began sarsaparilla decoction ; 
otherwise his health continued good. On the 16th March, however, a 
copper-coloured eruption, consisting of blotches variously sized and very 
numerous, came out on body and limbs. The eruption was unattended 
by fever. 

He now consulted a third practitioner, who ordered him to rub in 5SS. 
of strong mercurial ointment, twice daily. His mouth became very sore on 
5th day, when rubbings were discontinued for a few days, but were then 
resumed, and continued for seven weeks longer, during which time he 
confined himself to his room, and was very careful as to his diet. On the 

11th May, the frictions were discontinued, as Mr. pronounced him 

cured, and safe from all danger of relapse. Observe that his mouth had 
been decidedly affected this time ; profuse salivation had not been main- 
tained, but his gums were tender, and a slight salivation existed all along, 
after the violent salivation which arose on the 5th day had subsided. 

The patient took great care of his health during the summer and autumn. 
He continued quite well until the 9th of September, when he got an ulcer 

in his throat. He again applied to Mr. , who at first insisted (in 

self-defence, no doubt) that the sore throat must have been occasioned by 
new infection. This the patient truly denied ; on examining the ulcer 

Mr. asserted that it arose from the original syphilitic infection, and 

he immediately put him on the daily use of a quarter of a grain of corro- 
sive sublimate. He touched the ulcer several times with nitrate of silver 
in solution ; the throat got well on the seventh day, but, by way of secur- 
ing the constitution, the quarter-grain daily dose of corrosive sublimate 
was continued. 

On the 1st of January, 1838, another ulcer formed in the throat ! Mr. 

now increased the corrosive sublimate to half a grain daily, touched 

the ulcer several days in succession, twice daily, with butter of antimony ; 
after some days only once daily. 

On the 10th of January ulcer was healed. The use of the concentrated 
syrup of sarsaparilla was added, and the half-grain of corrosive sublimate 
was continued until Friday, 2d of March. 

I need scarcely record, that he was then in an extremely debilitated 
state, for the length of time he had been taking corrosive sublimate had 
been enough to impair the power of his stomach, so that for two months 



328 CLINICAL MEDICINE. 

he had lost all appetite, and he was likewise slightly jaundiced. By the 
way, when mercury has been used by a patient to excess, jaundice is by 
no means an uncommon consequence — a fact we had often occasion to 
verify in the Lock Hospital 20 years ago. 

The above case is instructive likewise, proving, as it does, that the 
same venereal poison in the same constitution may give rise to cutaneous 
affections of different species, for it here at first produced tubercular pus- 
tules, and at a subsequent period copper-coloured blotches. 

When this patient was placed under my care, I looked on him as a 
victim to a plan of treatment injudiciously persevered in for months after 
mercury was no longer necessary. Accordingly I discontinued that 
mineral altogether, and the patient completely recovered. It is difficult 
to imagine what train of reasoning could have misled the practitioner in 
this case. But to return to the causes which impede or prevent the bene- 
ficial action of mercury. 

Every excess — every thing, in fact, which injures the health of body 
or mind — will have a tendency to counteract the beneficial effects of mer- 
cury on the disease. I think much mischief has been done by the well- 
known assertion of John Hunter, that he could not see what harm a good 
dinner and a bottle of wine would do to a man taking mercury for chan- 
cre. I would not advise you to undertake to administer mercury in vene- 
real cases unless the patients are willing to submit to your directions ; — 
be careful in matters of diet, avoid intemperance, and confine themselves 
to bed, or at least to their rooms. 

It is the subjection to strict regimen, quietude, and confinement which 
seems to act so favourably in the case of soldiers. They are confined to 
hospital, obliged to keep their beds or rooms, deprived of all dietetic sti- 
mulants, and removed from all causes of mental emotion, and hence it is 
that their chancres heal so rapidly. Mercury will seldom do much good 
unless taken under proper regulations. It will affect the constitution va- 
riously, but in general injuriously. I have already mentioned one case 
in which it acted injuriously, in consequence of indulgence ; allow me to 
give another case of the kind arising from a different class of causes. A 
young gentleman at college, who was under my care for chancre, was 
taking mercury for some time during the summer season. He had taken 
some blue pill with benefit, and thinking if one or two pills were good, a 
large number would be better, he took them much oftener than he was 
ordered. 

An election took place at the college ; he went to see it, became ac- 
tively engaged in it, and continued so until a late hour in the afternoon. 
The weather happened to be extremely warm, so as to oblige him to 
change linen three times during the day, but the excitement produced by 
the election was such, that he forgot the condition he was in, exposed 
himself to avast deal of fatigue, and remained fasting the whole day. In 
the evening he went home, and took a large glass of wine. In the course of 
a few minutes his head was violently affected, he became quite delirious, 
and continued alarmingly so for twelve or fourteen hours. Here you per- 
ceive the mercury affected the head, producing violent delirium. In 
other cases it will give rise to coma. In fact, it would be difficult to 
enumerate the various modes in which it may act injuriously when ad- 
ministered without caution, or when the patient is exposed to disturbing 
influences during a mercurial course. 



SYPHILIS. 329 

You will recollect that some time ago, in speaking of double or com- 
plex diseases, I brought forward several facts in support of the hypothesis, 
that persons may labour under several diseases at the same time, all of 
which may combine to form an impaired state of the general system. In 
confirmation of this assertion, it appears that mercury may be employed 
for the treatment of syphilis, so as not only to leave the disease untouched, 
but also to superinduce mercurial cachexy, and even scrofula, and in this 
state you may have eruptions of various kinds. This is one of the worst 
forms of complex disease that comes under, the notice of the practical 
physician. It was this form of disease which exhibited so many melan- 
choly spectacles in the Lock Hospital some years ago : patients were seen 
labouring under all the horrible symptoms which combined syphilitic, 
scrofulous, and mercurial cachexies present — the glands, skin, throat, 
bones, mucous, synovial, and fibrous tissues, were all simultaneously 
affected ; in fact, almost every tissue in the body was more or less en- 
gaged, and the patients died terrible examples of the frightful ravages of 
complicated disease. 

In endeavouring, therefore, to analyze the nature and character of 
syphilis, you must always hold one great object in view, viz., to ascertain 
as closely as possible the order of the symptoms. Let us, for example, 
take the case of the woman in the chronic ward, who is at present labour- 
ing under nodes. The first object here is to inquire whether they are 
syphilitic or mercurial ; and with this view it will be necessary to obtain 
an accurate history of her case — to ascertain the order of symptoms — how 
long and in what manner she used mercury — what relief she has obtained 
— and whether the symptoms of relapse have come on slowly and gradu- 
ally, or rapidly and at once. 

If a person labouring under a certain class of symptoms, primary or 
secondary, has used mercury until his mouth has been affected, and if, 
when he has reason to think himself cured, his mouth being still tender, 
or having been so lately, if such a person, after exposure to cold, gets a 
violent attack of pains, followed by periostitis, we may conclude that he 
has taken a sufficient quantity of mercury to cure his syphilis, and that 
his complaint is mercurial periostitis ; for here you have a train of symp- 
toms not referrible to the original cause. This is a very common case, 
and you will see numerous instances of it in labourers, and persons who 
are exposed to atmospheric vicissitudes while taking mercury. You will 
find on inquiry, that after they have been cured of the venereal symptoms, 
they have exposed themselves to cold while still under the influence of 
mercury, and have shortly afterwards been attacked with a new train of 
symptoms. In most cases the chances are that this sudden supervention 
of disease is not the effect of syphilis, but of mercury. An accurate ana- 
lysis of the history of the case, and a careful observation of the new phe- 
nomena, are then the only guides we have to enable us to arrive at a just 
conclusion. I stated at my last lecture that the mere fact of a considera- 
ble time having elapsed since the patient took mercury is no proof that 
the symptoms are not mercurial. I have over and over again met with 
cases of periostitis in persons who had been two, four, six, and even eight 
years without taking mercury. I was called the other day to see a lady 
whose mouth was sore, and her breath fetid ; in fact, who presented all 
the phenomena observed in cases of mercurial salivation ; and yet it is 
now several years since she took mercury by the advice of an eminent 



330 CLINICAL MEDICINE. 

Dublin physician. Now, if so much time could have passed by, and yet 
one of the immediate effects of mercury be present, it is not improbable 
that some of its remote effects should appear after a lapse of time in which 
we would suppose that the mercury had been completely removed from 
the system. Many facts, however, can be adduced to show that some 
constitutions, when thoroughly affected by mercury, are apt to retain it 
for a very considerable time, and hence the practical physician is led to 
the reflection, that it should be used only in cases of necessity, and with 
all due discretion. Thus, in treating rheumatism, if you can cure by 
bleeding, leeching, tartar emetic, Dover's powder, and colchicum, you 
should not have recourse to mercury. The same observation will apply 
to the treatment of pneumonia, hepatitis, and many other forms of inflam- 
mation. 

In a letter which I have just received from Sir James Macgrigor, he 
informs me that mercury is very little used in the army. There is no 
regiment or hospital from which it is wholly excluded ; but it is adminis- 
tered with discretion, and only when the necessity of the case plainly 
requires its employment. I may observe, en passant, that you will find 
some excellent observations on mercurial remedies in the lectures of Dr. 
Sigmond, published in the Lancet. 

There is one remark I wish to make with respect to mercurials, namely, 
that an undue preference is shown to some preparations to the exclusion 
of others. I think, for instance, that calomel is too often employed where 
other preparations would answer better, and that corrosive sublimate is too 
much neglected. I have witnessed its superiority to other preparations 
of mercury, in many instances ; and some practitioners prefer it in the 
treatment of many forms of secondary syphilis. Thus, in a patient 
labouring under secondary symptoms, after the fever is over, and the 
eruption begins to decline, corrosive sublimate may be used with great 
advantage. One-eighth of a grain may be given twice a-day, and every 
night the patient may rub in from a scruple to half a drachm of mercurial 
ointment. Under this treatment, the disease is cured much more rapidly 
and effectually than if calomel or blue pill, or mercurial inunction alone, 
had been employed. 

In throwing out these observations on the treatment of venereal, my 
object has not been to enter into specialities, but simply to furnish a few 
general rules for the guidance of persons engaged, or about to be engaged 
in the treatment of one of the most important diseases in the whole noso- 
logy. You will find any additional information you want in books. An 
immense quantity of valuable information has been collected by the army 
surgeons ; and — thanks to the indefatigable industry of Sir James Mac- 
grigor — the profession and the public are now able to avail themselves of 
those valuable contributions to medical science. You will find much 
valuable matter in the Medico-Chirurgical Review, which contains an 
able analysis of Mr. Colles's work on Venereal. 

Ricord's work has been very ably reviewed in the Edinburgh Medical 
and Surgical Journal for July, 1838 ; and to that periodical I must refer 
you for details, merely remarking, that no modern author has done more 
than Ricord, by contributing materials calculated to decide many import- 
ant controverted questions. 

Fricke remarks, that although affections of the bone and periosteum 
are a very frequent effect of the syphilitic poison per se, yet caries and 



SYPHILIS. 331 

destruction of the bone are seldom or never observed, except when mer- 
cury has been administered. This observation is, generally speaking, 
correct; but, nevertheless, it requires some limitation : for I have seen 
examples of caries of bone in the venereal disease, where not a grain of 
mercury had been taken. In the cases I allude to, the scrofulous diathesis 
was pre-eminently marked, and the affection of the bones, which the 
venereal poison excited, immediately degenerated from its usual course, 
and assumed all the characters of scrofulous disease. In both instances, 
destruction of the nasal bones, and consequent sinking in of the bridge 
of the nose, occurred — a deformity occasionally of simple scrofulous 
origin. 

From an analysis of PirogofTs " Surgical Annals," published in Op- 
penheim's Journal, Sept. 1838, it appears that mercury is very seldom em- 
ployed at Dorpatfor the cure of venereal, and yet Dorpat is remarkable for 
the number and severity of syphilitic cases — a circumstance partly attributa- 
ble to the absence of medical surveillance over the women of the town, 
and partly to the apathy, carelessness, and fdth of the lower orders. 

PirogofTs general mode of treatment is non-mercurial ; and he main- 
tains that relapses are less frequent and less violent than when mercury is 
employed as the general means of cure. It is worthy of remark, that a 
peculiar consequence of phymosis, or its causes, is frequently observed at 
both Dorpat and Petersburg, and which consists in the transformation of 
the inner layer of the prepuce into firm cartilage. There is no remedy 
for this but circumcision. This change into cartilage is always produced 
by diseases which, producing phymosis, at the same time give rise to a 
long-continued irritation and inflammation of the inner surface of the 
foreskin, attended with an increased secretion from the latter. Under 
such circumstances, the surfaces of the glans and its covering prepuce 
pour forth secretions of an offensive nature, and which find a very diffi- 
cult vent, and are, besides, rendered more acrid by an occasional admix- 
ture of urine, and by the impossibility of thoroughly cleansing the parts. 

This conversion of a submucous cellular layer into canilage occurs 
also in the intestinal canal. In March, 1S31, two examples of it were 
observed by Dr. Nalty and myself, at Sir P. Dun's Hospital. One of 
these cases was very remarkable, as the submucous cellular tissue of the 
colon was converted into cartilage over an extent of eight or nine inches 
in length, and occupying the whole circumference of the gut in that part, 
so as to form a complete cartilaginous cylinder, about a line in thickness. 

This tract of intestine seemed therefore formed of four distinct coats, 
viz. : — mucous, cartilaginous, muscular, and serous. The cartilage was 
firm in its structure, very pliable, though strong, and its deposition seemed 
to have produced no change in either the calibre or shape of the intestine. 
This morbid production was evidently connected with a chronic inflam- 
mation of the mucous membrane, which had finally terminated in nume- 
rous ulcerations, and w 7 as accompanied by a copious deposition of black 
colouring matter, giving the membrane a mottled appearance. The 
blotches of black occupied by far the greatest portion of the surface, and 
were of a very deep shade, precisely similar to the colouring matter so 
often found in the bronchial glands and on the surface of the lungs. 

In the healthy European this black colouring matter is not found, ex- 
cept on the surface of the lungs, and in the chorion, where it forms the 
pigmentum nigrum. In the negro this colouring matter occurs likewise 



332 CLINICAL MEDICINE. 

in the rete mucosum, producing the black skin which distinguishes that 
variety of mankind. We thus see that in the white as well as the negro, 
not only do the vessels of certain organs enjoy a power of secreting black 
colouring matter during health, but that likewise during disease other 
parts of the body, as in the cases I have cited, may assume a similar ac- 
tion, and secrete black matter. In some whites this tendency to secrete 
black matter becomes excessive, and gives rise to certain forms of mela- 
nosis, where this matter is secreted in almost all the tissues of the body ; 
for I cannot agree with Faudrington in thinking, that the experiments of 
M. Barruel, or those of Dr. Henry, are sufficient to establish a marked 
difference between the colouring matter of melanosis and that of the rete 
mucosum of the negro, or the pigmentum nigrum of the white. The 
melanotic patches are, no doubt, often of a different shade, but very fre- 
quently they are extremely black. 

Be this as it may, the black matter in the intestines I have described 
was clearly of the same nature as that on the surface of the lungs of the 
white, or the rete mucosum of the negro. This subject is interesting, 
because a knowledge of the fact, that the black colouring matter which 
imparts to the skin of the negro its peculiar hue, is also a natural secre- 
tion in certain organs of the white during health, and is likewise in the 
latter a frequent product of disease — I say a knowledge of this fact is of 
great weight, proving that the black colour of the skin cannot constitute 
a difference of species. With regard to the hair, which is often the seat 
of a probably similar colouring matter in the white, I may observe, that 
one fact, not hitherto attended to by physiologists, is in itself sufficient to 
establish that the hair is a horny tissue, in which a certain circulation is 
maintained. The fact to which 1 advert is, that the hair often begins to 
grow grey at its extreme point, or the end furthest from the root. Here 
the colouring matter is often absorbed, while it still remains in the re- 
maining portion of the hair. The phenomenon of plica polonica, so ad- 
mirably described by my friend, Dr. Kowalowski, in the Dublin Medical 
Journal for November, 1838, establishes the vitality of the hair. 

Postscript. — Having witnessed the very judicious treatment pursued 
by Dr. Tuohill, of Clare-street, in some embarrassing cases of syphilis, I 
requested he would briefly detail their particulars, and explain the mode 
of treatment. I shall now lay before the reader Dr. Tuohill's communi- 
cation, which, from the well-known talents and acquirements of the author, 
I consider entitled to the greatest attention. 

" Whether that peculiar form of the venereal disease, commonly called 
1 the Phagedenic,' be the result of a distinct morbid poison, or a mere mo- 
dification of what we more commonly meet in the course of practice, there 
can be no doubt that it is both a very formidable and a very unmanagea- 
ble affection. This observation applies equally to the constitutional as 
well as to the local symptoms in whatever relation the one may be supposed 
to stand towards the other. Though much difference of opinion may ap- 
pear to exist respecting its precise nature very little can be discovered in 
the consideration of those principles of treatment that are deemed fittest 
for adoption. All men of experience are agreed on the necessity of check- 
ing the ulcerative process, and fortifying, or at least supporting the bodily 
health, indications which it is usual to attempt accomplishing by those 
external applications comprehended under the class of sedatives, stimu- 



SYPHILIS. 333 

lants, escharotics, and (save in the existence of vascular excitement of the 
system generally) the internal use of sarsaparilla, nitric acid, the various 
preparations of iodine, bark, iron, &c. with such directions as to climate, 
diet, and regimen, as circumstances may demand. The signal indifference 
which phagedenic ulceration frequently exhibits to the influence of so many 
and such valuable remedial means would go far in showing, either that 
they are badly adapted towards the promotion of a cure, or that the dis- 
ease is of such a nature that time must constitute an essential element for 
its removal out of the system. The latter idea may be sustainable whether 
we conceive that in the long run the resources of the constitution alone have 
the power of neutralizing the innate virulence of the disease, or that, after 
running its natural course, it becomes so mild as to enter on, or approach 
to, a spontaneous cure, requiring but little if any assistance from medicine. 
Whatever reputation mercury may have deserved in other forms of the 
venereal disease, in this at least it can lay claim to little. It is not its ne- 
gative so much as its positive powers that disentitle it to the character of 
a remedial agent. The serious mischief which even a moderate use of the 
remedy so frequently entails, both on the constitutional and the local symp- 
toms, would seem to justify its rejection altogether. Still, strange though 
it may appear, there are occasions where its beneficial effects have been 
most surprising, that is, so far as the accomplishment of a perfect and per- 
manent cure, under circumstances otherwise hopeless, would warrant the 
expression. It is a matter of much regret, however, that we have no sys- 
tematic arrangement or complication of such cases — no faithful record of 
the precise circumstances under which mercury has proved so successful 
when all other means failed. The statements of medical men on this head 
are vague, general, and even contradictory. No special rules as a guide 
to the practitioner in any given case are laid down. Some are of opinion 
that the most seasonable period for a trial of mercury is when the consti- 
tution has rallied from the sympathetic effects of the local disease. Others 
look upon it in the light of a dangerous experiment, a kind of * dernier re- 
sortf admissible only in extreme cases when the ulceration is rapidly 
spreading despite of all attempts to arrest its progress. Others again say, 
that mercury may be given with advantage in small doses as an alterative, 
but they tell you to watch and wait till the ulcerative process shall have 
assumed a chronic form resembling in features and complexion an indolent 
ulcer. 

" Having premised thus far, I shall now detail the essential particulars 
of a case of phagedenic ulceration which resisted all the ordinary means 
of treatment with others of rather an experimental nature, and at last 
yielded to remedies, which, as far as I can collect, were never before ad- 
ministered in the same affection. J. C, aged 34 years, of a florid com- 
plexion, and robust figure of body, arrived in Dublin from the South of 
Ireland, on the 6th of October, 1S39, for the purpose of placing himself 
under medical advice. He was confined to his bed the week previous, 
and suffered much from a large bubo in the right groin, which now pre- 
sented a distinct sense of fluctuation. The tumour was noticed on the 2d 
of September, and reached its present size notwithstanding the application 
of a great many leeches and iodine ointment. He was also put under the 
influence of mercury, which he had been taking for five weeks. So far 
back as the loth of August, he contracted a chancre, which, as not appre- 
hending infection, he neglected for the first fortnight, but healed speedily 



334 CLINICAL MEDICINE. 






by the application of black wash and nitrate of silver, leaving neither hard- 
ness nor any other trace of its existence behind. 

" It appears, from the gentleman's statement, that in the summer of 
1832, during a convalescence from influenza, a venereal eruption was 
discovered over his body by his medical attendant : the mucous mem- 
brane of the nose was also in a state of ulceration. He got some warm 
baths, and had taken for the space of a month Plummer's pills with sar- 
saparilla. Black and yellow washes were injected into the nose. The 
eruption very soon disappeared, but the affection of the nose continued 
for more than two months. Ever since that period, crops of pimples 
which scale away, are in the habit of appearing on his poll and at the 
roots of his hair ; and the firm conviction of his mind was, that the dis- 
ease still existed in his blood. He conceived that the fact of his now 
being laid up may turn out as a fortunate event in his life, by obliging him 
to attend to himself, and thereby getting totally rid of the two diseases. 
I opened the bubo, gave vent to a large quantity of laudable pus, applied 
poultices of bread and milk for a few days, following them up with sim- 
ple dressing and compresses. The cavity progressively contracted, and 
the surface of the cut presented a healthy appearance — no disposition to 
callous edges or the formation of sinuses. The internal treatment con- 
sisted of quinine, sarsaparilla and nitric acid, nourishing diet, and wine 
in moderate quantity. Towards the end of December he went home, 
considerably improved in health, with a small ulcer not more than an inch 
in length, the remains of the bubo. He returned to Dublin early, in May, 
with an ulcer larger than the size of a pigeon's egg, internal to the situa- 
tion of the first ulcer, but originating from it after the application of nitrate 
of silver. It was stuped with opium ; black wash and acetate of lead 
lotion were also used. All irritability subsided ; the ulcer became sta- 
tionary and exhibited an indolent character. Taking other circumstances 
into consideration, I conceived the occasion favourable for mercury, and 
brought him under its influence. The mouth was kept sore for a. fortnight, 
but no favourable impression was made on the ulcer ; on the contrary, it 
became irritable, with a bloody discharge, in addition to which the sto- 
mach became deranged, and the rest much interfered with. June 17th, 
Mr. Cusack was called in consultation. He conceived that the impaired 
state of the constitution modified the ulcer and rendered it unmanageable, 
and proposed change of air as the safest and best means of checking the 
evil. The only medicines he would then set value on were sarsaparilla 
and hydriodate of potash, but expected some improvement from strapping 
the ulcer with real adhesive plaster, and the use of nitric acid as a lotion. 
These suggestions were strictly adhered to, and a full trial given. The 
health was benefited, but no improvement was observable in the ulcer ; 
its edges were burrowed, and the skin, at its inner margin, became livid, 
hard, and granular to the touch. A pustule appeared at the upper angle 
of the ulcer, which, on bursting, increased rapidly, and ran into the ori- 
ginal seat of the disease, giving to the whole a crescentic figure. As 
those changes had occurred under circumstances so favourable to the im- 
provement of the general health, I arrived at the conclusion, that the ill- 
conditioned state of the ulcer was the result of other causes than those of 
a general constitutional nature ; and with a view 7 of counteracting what I 
conceived an old venereal taint, gave a trial to the muriate of mercury ; 
I prescribed one-twelfth of a grain, in the form of pill, to be taken twice 



SYPHILIS. 335 

a-day. In the course of ten days, a most remarkable improvement was 
observable ; the inflammatory hardness of the neighbouring skin disap- 
peared, the ulcer granulated, and diminished to one-fourth its size. The 
most sanguine hopes of recovery were naturally entertained, when, most 
unexpectedly, a sense of rigor was felt ; the stomach became irritable, 
and a complete loss of appetite followed ; the secretion of the ulcer was 
suppressed ; it became hot, painful, and disposed to bleed. Opiate pills, 
with stupes, afforded relief from the pain, but the ulceration proceeded, 
removing, in its progress, all the newly-formed structure. Mr. Cusack 
was again called in : after paying a few visits, he expressed his convic- 
tion of the hopelessness in expecting anything like an immediate cure by 
specific remedies. On the 24th of September, all but twelve months 
since the patient's first arrival in Dublin, he was obliged to return home 
on matters of urgent business. Mr. Cusack and I met for the purpose of 
laying down rules for his observance. He remained at home four months, 
used constantly the sarsaparilla and hydriodate of potassa, dressed the 
ulcer with red precipitate ointment, with the occasional application of 
nitrate of silver. In February 3d, 1841, he returned to Dublin, with a 
crop of leprous eruption on his body and extremities. In the situation of 
the nates, they were large and showed more of a pustular form. Mr. 
Cusack, having first witnessed the beneficial effects of Mr. Dona van's 
preparation of iodine, arsenic, and mercury, in cases at Steven's Hospital, 
was anxious to give it a trial. It was given in graduated do<es, and pushed 
so largely as to produce nausea, constriction of the cesophagus and palpi- 
tation of the heart. 

" Those powerful medicines exerted a very decided and manifest in- 
fluence over the eruption, banishing every vestige of it in four days, but 
made not the least impression on the ulcerative process, which at the 
time happened to be in a state of unusual exacerbation. The ulcer ap- 
peared extremely sensitive, of a fiery red colour, with irregular fungous 
granulations, extended its ravages along the side of the scrotum to the 
perinaeum, where it terminated in a kind of sinuous pouch. The suffer- 
ings of the patient were now indescribable ; opiates, in large doses, fail- 
ing to procure rest, and scarcely alleviating the intensity of the pain. 
The stronger caustics, such as nitric acid, muriate of antimony, and kali 
purum, were alone capable of checking the morbid action, and affording 
relief. Even nitrate of silver seemed insufficient to arrest the onward 
progress of the disease. The exacerbation lasted for three weeks, caused 
much bodily exhaustion, and left the nervous system in a very irritable 
condition. He was moved to one of the outlets of Dublin, and put under 
a course of tonics and bitters. The appetite and strength improved, and 
the ulcer, though still maintaining its characteristic figure and features, 
became comparatively bearable ; the pain amounting to mere irritation, 
and the ulceration being partial, yielding to a weak solution of nitrate of 
silver. 

" In April, the ulceration became quite stationary and continued so in 
May. Mr. Cusack and I then agreed that a stimulus of some kind was 
requisite, and conceiving it not improbable that the present appearance 
indicated at least a toleration of mercury, we came to the conclusion of 
giving the remedy a fair trial, at the same time watching its effects, and 
guarding against any mischief that may seem to arise. May 21st, half a 
drachm of mercurial ointment was rubbed in at night, and the ulcer 



336 CLINICAL MEDICINE. 

fumigated with the hydrargyrum cum creta. Those remedies were kept 
on for the space of three weeks, until the gums were sensibly affected ; 
still no visible change or improvement of any description could be dis- 
cernible, but in the course of a short time a sense of general weakness 
and nervousness was complained of, which, to a considerable extent, 
gave way to the use of quinine, bitter infusions, and a rather liberal 
allowance of claret, with nourishing diet. 

" August 2d, Mr. Colles was called in consultation ; he recommended 
the ulcer to be fumigated with the red candle, and a very small, quantity 
of mercurial ointment (ten grains) to be rubbed into the inside of the 
thigh, night and morning — a mode of administration which he found 
successful in similar cases of long standing. This plan of treatment was 
persevered in for upwards of three weeks, without the least encourage- 
ment, according to Mr. Colles's own admission, to proceed any further. 

" September 10, Sir Philip Crampton next joined in consultation. It 
was his idea that a complete removal of the diseased surface offered the 
surest and speediest means of accomplishing a cure, and by his advice a 
saturated solution of nitrate of copper was poured over the ulcer so per- 
fectly as to enter every fissure and crevice. It had the effect of giving 
rise to the most agonizing sensation of torture, which lasted several hours, 
but when the suffering ceased, it is almost incredible what a degree of 
ease and comfort w T as experienced. The countenance brightened up 
and totally lost that haggard cast of expression so peculiarly characteristic 
of the disease in its aggravated form. A large slough, apparently com- 
prising the entire morbid mass, came away, leaving a clean smooth surface 
behind. Healthy granulations preceded ; the ulcer contracted, and ob- 
viously seemed disposed to fill up, when, without any assignable cause, 
it relapsed into its old condition. The succeeding winter, including 
the commencement of 1842, he spent for the most part in the country. 
Sarsaparilla w r ith hydriodate of potash, w r ere in constant requisition, and 
a great variety of local applications were tried, viz., carbonate of iron, 
the acetates of lead and copper, muriate of mercury, arsenic, with cicuta 
and carrot poultices. The onward course of the malady had thus received 
some partial check, but no impression of consequence could be sustained. 
The ulceration increased upwards and laterally towards the left groin, 
burrowing deeply at the root of the penis. 

" March 10, Dr. Graves was now called on to- consult with Mr. Cusack 
and me. After a full inquiry into the history of the disease, he dwelt on the 
necessity of closely attending to the state of the general health, and pro- 
posed, by way of a trial, the oil of cod-fish, which was taken to the amount 
of 10 oz. in teaspoonful doses twice a- day ; its effects, as far as observa- 
tion could go, were strictly of a negative character. 

" During the months of April and May, the ulceration proceeded more 
or less actively, and engaged a large section of the root of the penis. 
The strength much declined, and the loss of flesh was very palpable ; the 
stomach was disordered, and a torpidity of the kidneys supervened, 
inducing or coexistent with tension of the abdomen. The latter affection 
was accompanied with considerable distress, and gave way but imperfectly 
to aperient and diuretic medicines. The situation of the patient was 
now a subject of anxious concern to his friends : the break up of his 
constitution was so shockingly perceptible, and he himself frequently 
made allusion to the case of a very near relative, who, while labouring 



SYPHILIS. 337 

under similar symptoms, fell a victim to dropsy. Whatever value may 
be set on the force and faithfulness of such an analogy, it at least con- 
tributed to convey both to my mind as well as to that of Mr. Cusack, no 
small share of apprehension ; and as we were considering what further 
remedies worthy of trial were within our reach, we selected creosote for 
internal use, and extract of belladonna for external application. We had 
no authority for such a selection ; it was purely one of an experimental 
character. We felt that remedies of a powerful nature were indicated, 
and it was a main object to hit on those that could do the least possible 
injury — a recommendation though negative, still in the present instance, 
perhaps, of vital importance. The belladonna was applied twice a-day ; 
about the size of a large pea of the extract, diluted with a dessert spoonful 
of water was poured on the ulcer, and after being allowed to rest for a 
few minutes, it was covered with lint and oiled silk. The creosote was 
formed into an emulsion in the proportion of 12 drops to 8 oz. and two 
tablespoonfuls were given three times a-day. Both medicines were made 
use of without a day's intermission from the 8th of June to the 7th of 
August, when the healing process was completed. The good effects of 
the medicines, both on the constitution and the local disease,* were clearly 
perceptible after the first week's trial, and every succeeding day afforded 
undeniable evidence of a steady and progressive course towards a recovery 
so long delayed and so anxiously hoped for. 

" Whatever value future experience may attach to the treatment 
adopted at the close of the above long scene of suffering, there can be no 
question that to it alone is attributable the happy and fortunate result that 
followed. The recovery succeeded the remedy in the strict order of cause 
and effect, without an incident or coincident to qualify or weaken their 
just and respective relations. It cannot be said that time constituted an 
active or essential ingredient in bringing matters to a successful issue ; 
the change was too rapid. There was no harbinger of the glad event, no 
one favourable feature to be discovered that could tend in the least de- 
gree to inspire hope or encourage confidence. The constitution did not 
triumph over the disease ; it rather sunk beneath its repeated assaults. 
The disease itself showed no perceptible indication of decline ; it still 
stood at its acme of virulence, and, all things considered, the case at no 
former period presented so gloomy and unpromising a complexion. The 
first signs of improvement were perceptible in the constitution — the secre- 
tion of urine increased, and the abdominal fulness subsided, the appetite 
returned with natural sleep, and a consciousness of additional strength 
was felt in every limb. Before the ulcer exhibited any sensible alteration, 
' the burning gnawing pain,' as the patient graphically so denominated it, 
completely abated, and the discharge gave less of the dark stain to his 
linen. The healing process first filled up the deep chasm at the root of 
the penis, then the upper horn of the ulcer granulated ; the neighbouring 
skin lost its livid hue and became soft ; the convex margin of the ulcer 
flattened down and exhibited a white pellicle, an appearance which con- 
vinced me that at length and at last a recovery was at hand, for at the 
former period when the ulcer was reduced to so small a size, the convex 
margin still continued hard and elevated with a serrated edge." 

41 I shall now subjoin another case of phagedenic ulceration, which has 
been occasionally for the last year and a half under my care. Mercury 
succeeded in the end, though at an early stage of the illness it proved an 
23 



338 CLINICAL MEDICINE. 

utter failure. The recovery was both sudden and unexpected. My chief 
object, however, in giving it for publication is to direct the attention of 
the profession to certain appearances in the condition of the parts affected, 
which it may be found of importance to attend to in coming to a decision 
as to the propriety of exhibiting mercury. The patient was a young man, 
26 years of age, with a naturally strong and healthy constitution. The 
first time I attended him was in August, 1840. He was then affected 
with a swelled testicle, complicated with hydrocele, which I found to be 
venereal, and from which he completely recovered after having rubbed in 
half a drachm of mercurial ointment twice a-day for three weeks. At this 
time I observed marks of ulceration on his back and thighs, and learned 
from him that in the month of December previously (1839), he had taken 
mercury for the cure of a venereal eruption. He consulted me again in 
February, 1841, for a large painful ulcer with hard, overlapping edges, 
situated above the middle of the right clavicle. It measured three inches 
in length, and one and a half in breadth, of a semicircular figure, with its 
convex margin internally towards the neck. The adjoining skin, particu- 
larly at the convex margin, was hard, and of a livid colour. It made its 
appearance about three months previously, and was treated with several 
ointments and other local applications without producing the least benefit. 
The health did not seem to have suffered much, though on several occa- 
sions the rest was interfered with in consequence of the darting pains. I 
removed the callous edges with a scissors, and stuped the part with warm 
water and laudanum, at the same time encouraging the bleeding. I pre- 
scribed pills of opium and cicuta, which were continued for a week. The 
margins of the ulcer, and a few ulcerating points on the surface, were 
touched with nitrate of silver, and unguentum aBruginis was subsequently 
used for dressing. Sarsaparilla, nitric acid, and hydriodate of potash 
were administered steadily until the 10th of May, when on plainly ob- 
serving no advantage to be derived from a further pursuance of the treat- 
ment I commenced putting him under the influence of mercury. He 
rubbed in two ounces of ointment, and took two and a half dozen of 
Plummer pills. His mouth remained sore for nearly three weeks. Not 
the slightest change for the better was observable in the ulcer or neigh- 
bouring skin. The granulations were more disposed to bleed, and small 
ulcerations made their appearance on the surface. The mercury evidently 
disagreed with his stomach, he also felt weak and had an irritability of 
the pulse. The cold infusion of sarsaparilla on lime-water was now pre- 
scribed, which, together with a compound rhubarb pill every second day, 
agreed in a remarkable manner ; but still he complained of debility, with 
a tendency to perspiration on making any unusual effort. The sarsapa- 
rilla was persevered in till the end of July, and, during the interval, the 
applications in use were yellow-wax ointment and nitrate of silver, and 
on two occasions, the muriate of antimony. In August, he went some 
distance into the country, and, while there, was visited by a medical 
friend, who dressed the ulcer with red precipitate ointment, and applied 
the sulphate of copper solution. He used no internal remedies of any 
kind. In October 22d, he returned to Dublin, seemed in better health, 
but rather thin. The ulcer had increased in size, its lower corner passing 
below the clavicle ; the surface presented several large round granula- 
tions, with scarcely any degree of sensibility, and the burrowing towards 
the convex margin was very deep. I cautiously removed the edges and 



SYPHILIS. 339 

the more prominent of the callous granulations with kali purum, and fol- 
lowed it up with the nitrate of silver solution, varying its strength accord- 
ing to circumstances. Having thus produced a beneficial change on the 
whole surface of the ulcer, I entered on the use of black wash, with weak 
precipitate ointment, and gave the sarsaparilla with hydriodate of potassa 
another trial. An improvement was supposed to take place, but, strictly 
speaking, things were at a stand-still until the end of December, when 
the strength speedily gave way with a decided loss of flesh ; and he felt 
so weak as to be totally incapable of attending to the lighter occupations 
of business. He had, therefore, to retire and go again to the country, 
where he continued till the beginning of May, 1842. He had taken no 
medicine, save two large bottles of Peruvian bark, in wine, in order to 
combat the debility which he laboured under. In the mean time, the 
ulcer was dressed with yellow ointment, and sulphate of copper was ap- 
plied to check the fungous granulations. In April 22d, I received a com- 
munication from a relative of his in the country, with whom he was re- 
siding, informing me that his looks were most ghastly, and that he had 
scarcely any flesh on his bones, and suggested, that as the country had 
done him no service, it was his best plan to go into a hospital, where 
every comfort could be acquired on the payment of a certain sum. As 
such an alternative was very repugnant to the patient's feelings, he was 
by no means willing to enter on it with any thing like a serious intention. 
He arrived in Dublin on the loth of May, and called on me on the 20th. 
His debility and emaciation were extreme ; his tone of voice was even 
altered. In a marked tone of despondency he reminded me how mistaken 
I had been in supposing that country air could cure so inveterate a dis- 
ease as his was. He declined entertaining the question of the hospital, 
and seemed desirous of making me feel that the responsibility of his case 
was altogether on my head. 1 saw plainly, that some decided steps should 
be taken, as all the non-mercurial remedies had failed. I was contem- 
plating the adoption of Mr. Colles's plan of rubbing in small quanti- 
ties of mercurial ointment, when I recalled to my mind the close 
resemblance which this ulcer bore to one of a similar nature, which 
yielded to calomel and opium, I, therefore, notwithstanding the alarming 
exhaustion, had the less hesitation in proceeding. He commenced on the 
21st of May, taking a grain of calomel and \ grain of opium, twice daily. 
On the 13th of June his gums became sore, and I reduced the quantity to 
one pill a-day, which was sufficient to keep up the tenderness of the gums, 
and on the 6th of July, I deemed it unnecessary to persevere any further 
with the medicine, as no vestige of the ulcer was remaining. During the 
period of the healing process, the only dressing made use of, consisted of 
Elemi ointment and white lead, in the proportion of one part of the latter 
to four of the former. The alterations in the local appearances which at- 
tracted my observation and which I am anxious to draw attention to, are 
as follows, viz., a change in the configuration of the ulcer from that of the 
ordinary crescentic to somewhat of an oblong shape ; the want of dis- 
tinction into convex and concave edges, and the absence of angular sharp- 
ness at either extremity ; more consistence in the discharge, with a ten- 
dency to scab ; the absence of fissures or callous granulations on the sur- 
face, and the complete disappearance of that peculiar granular hardness 
and lividity which were all along observable close to the convex margin 
of the ulcer. 



340 CLINICAL MEDICINE. 

" With respect to the sensible effect of the medicine, I could only col- 
lect, that at first it did not disagree (a matter of much moment to be ap- 
prised of) ; but after a fortnight the rest was natural and refreshing, and 
the appetite improved, both calming the nervous system, and imparting 
fresh vigour and life to the shattered frame. On the subsidence of the 
pain, which was greater than the complexion of the ulcer would seem to 
indicate, the centre granulated and skinned naturally, thus forming two 
separate ulcers, which speedily scabbed, shrunk and shrivelled away, leav- 
ing behind a perfectly sound and permanent surface. From this period 
the patient rapidly gained flesh and recovered strength. He is at this 
moment as healthy, and in the enjoyment of as good spirits as ever he 
had in his whole life." 

The plan of treatment adopted by Dr. Tuohill, in the preceding cases, 
has not been spoken of by any writer on the subject. That the creosote 
cured the first patient, there can be no doubt, and if the observations with 
respect to the proper period for giving mercury in phagedena be proved 
to be correct, we must regard Dr. Tuohill as having made the most im- 
portant addition to our knowledge of this disease since the introduction 
of the non-mercurial treatment. 

I have but few observations to make on the treatment of syphilis, in 
addition to those already announced. Since the preceding lectures were 
delivered, I have made some experiments on the comparative value of 
lunar caustic and sulphate of copper in healing chancres ; and I am fully 
convinced, that for this purpose we should prefer the latter. The great 
utility of lunar caustic in destroying the surface of the sore, in the first 
instance, is unquestionable ; but after this first application, I think we 
will succeed in rapidly healing the ulcer more effectually by sulphate of 
copper, which may be used either in substance or in solution of various 
strength, after the manner recommended for the nitrate of silver lotions. 
When the ulcer has assumed a chronic appearance, with thickened, ele- 
vated, and, as we frequently see, everted edges, I know of no escharotic 
more useful in levelling the edges and improving the surface of the sore, 
than the free application of this remedy in substance. I am also perfectly 
satisfied that the sulphate of copper produces much less irritation than 
the other, and that buboes more rarely follow its employment. 

There is one more point to which I am very anxious to direct attention, 
as I am certain many errors are committed by a want of knowledge on 
the subject. I have frequently had under my care, patients of a scrofu- 
lous constitution, affected with primary sores, which, for obvious reasons, 
were treated on the non-mercurial plan, and readily healed without bubo 
or any other bad symptom. Some of these patients were afterwards at- 
tacked with periostitis, produced by cold, wet, injury, or any other cause, 
and though they had never taken a grain of mercury, and were free from 
any other symptom resembling syphilis, have been pronounced to labour 
under secondaries by other practitioners to whom they have applied for 
advice. This view seemed in many instances extremely probable, from 
the fact that soon after the periostitis was established, nocturnal exacerba- 
tions, sweating and emaciation rapidly ensued. Such cases are by no 
means rare, and require the greatest discrimination ; for if mercury be re- 
sorted to with the impression that the patient labours under secondary 
syphilis, the most alarming consequences are sure to follow. The perios- 
titic pains may be relieved for a time, but they soon return, again mercury 



SYPHILIS. 341 

is had recourse to, and again the pains return ; in the meantime the con- 
stitution of the patient rapidly gives way under the combination of struma 
and the uncalled for administration of mercury. 1 have seen but too 
many instances of what I now state, and therefore I am particularly anx- 
ious to direct attention to these cases, which, as far as I can discover, 
have not been spoken of by writers on syphilis, struma, or periostitis. It 
may be asked, what are the distinguishing marks of these cases? I can 
only say, that in those which have come under my observation, the peri- 
ostitis followed the appearance of the chancres at considerable distances of 
time — many months or two, four, even six years intervening — it was un- 
accompanied by any form of eruption, and was not immediately attended 
by sweating, nocturnal exacerbation and emaciation ; there was no sore 
throat, or other unequivocal syphilitic symptom, circumstances which, 
when coupled with the fact that the sores on the penis were treated on 
the non-mercurial plan — a plan allowed on all sides to interfere less with 
the order of succession, and the natural combinations or forms of grouping 
of syphilitic symptoms, these circumstances, I say, constitute the basis of 
a differential diagnosis, which, when followed by the line of treatment 
indicated, leads to the happiest results. 

In all such cases mercury is inadmissible, and our chief reliance must 
be placed on iodine in its different forms, sarsaparilla, nitric acid, tonics, 
iron, nourishing diet. I have a few remarks to make with respect to 
hydriodate of potash, which I trust will not be considered superfluous. I 
have observed that this remedy will frequently cure periostitis and other 
affections when given in free doses, though the disease may have resisted 
its influence when given in small quantities. I am never dissuaded from 
trying it by the assurances of the patient or his medical attendant, that 
the remedy has already had a fair trial ; in such instances I begin with 
the doses usually ordered and increase the quantity daily, carrying it in 
some cases to half a drachm three times a day, a mode of administering 
this medicine I found extremely beneficial.* 

Hydriodate of potash does not appear to exercise the same powerful 
control over syphilis characterised by the copper-coloured eruption as 
over other forms, — these cases are more advantageously treated with cor- 
rosive sublimate and sarsaparilla, and this opinion accords with the views 
of Mr. Carmichael, who limits the administration of mercury to this form 
of the secondary disease and to the peculiar ulcer, which, according to 
his doctrine, precedes it, namely, the Hunterian chancre. There are two 
classes of cases in which hydriodate of potash is more particularly ser- 
viceable. The one includes those instances where the symptoms have 

* For a knowledge of the fact that hydriodate of potash should be pushed very far in cases 
of obstinate and frequently relapsing periostitis, I am indebted to ray friend, Surgeon U'Ferrall ; 
the following case illustrates the efficacy of this method. Mr. M. had severe periostitis, after 
long-continued mercurial treatment of syphilis, and was much reduced by frequently repeated 
salivations, — in August, 1839, Mr. Carroll of Meath Street, advised him to place himself under 
my care. From August to December, 1839, he took Jxvi. of hydriodate of potash, in five- 
giairi doses, gradually increased to ten grains three times a-day. His general health improved, 
he grew stout, and appeared quite cured, but towards the end of January, 1840, he relapsed, 
and again took the same medicine with temporary relief, — this happened several times, so that 
before December, 1840, he had consumed xxxiii. drachms more, — in that month he again 
relapsed, when I consulted Surgeon O'Ferrall. who advised a recurrence to the same remedy 
in much larger doses, and persevered in until all periostitic swelling, and every vestige of pain 
•was removed. He now took gss. three times a-day, until £xx. were consumed. He took on 
the whole from beginning to end 3 viii. and ^v. of this mineral, and has been perfectly well 
ever since ! 



342 CLINICAL MEDICINE. 

been set astray (so to speak), by the frequent and injudicious employment 
of mercury, — the other embraces those cases in which the periosteum, the 
bones, and the mucous membranes are entensively engaged, in the latter 
instance presenting ulcer of the nose, tonsils, pharynx, tongue, inside of 
cheeks and lips, usually associated with large and painful condylomata at 
the verge of the anus, and the mucous tubercles of the French writers on 
the scrotum, inside of thighs, &c. In such forms of the disease, hydrio- 
date of potash, either singly or in combination with sarsaparilla, are by 
far the best remedies we possess. We as yet want facts to determine 
accurately the comparative value of hydriodate, and corrosive sublimate, 
in those particular cases, which indicate to every practitioner, whether he 
be a non-mercurialist, or a mercurialist, the necessity of giving sarsa- 
parilla, tonics, good diet, &c. &c. 



PARALYSIS. 
LECTURE XXXII. 



General remarks on the pathology of paralysis — Dr. Graves's new views upon this subject — 
Their application to the study of several varieties of paraplegia — Explanation of Mr Stan- 
ley's case of paraplegia ; of Dr. Stokes's cases — Two cases of paraplegia after enteritis — 
Paraplegia after metritis — Paraplegia the consequence of poisoning by lead ; by arsenic — 
Paraplegia arising from irritation of the urethra (case communicated by Dr. Hutton). 

Having recently met with some very interesting and remarkable cases of 
impairment of the muscular functions of the lower extremities, I am anx- 
ious to offer a few observations on paraplegia, particularly while the sub- 
ject is still fresh in my mind: we can resume the consideration of our 
clinical cases at a future opportunity. I would entreat your favourable at- 
tention on this occasion, while I lay before you some opinions on paraple- 
gia peculiar to myself, and differing from the views entertained by the 
generality of medical writers; the subject, too, is one of extreme interest, 
involved in much obscurity, and offering an extensive field for investiga- 
tion : I trust, how r ever, I shall be able to communicate some new matter 
calculated to throw additional light on the nature of this affection, and 
thus contribute to fill up the blanks which exist in an important depart- 
ment of pathological medicine. 

You are aware that by paraplegia is meant that species of paralysis in 
which the lower extremities are affected — a paralysis frequently embracing 
loss of motion and loss of sensation in the lower extremities, accompanied, 
in many instances, with derangement of the muscular pow T er of the blad- 
der and rectum. Now, I wish you clearly to understand that it is not my 
intention to describe the symptoms, or discuss the causes of those species 
of paraplegia which are well ascertained, and of which you will find satis- 
factory descriptions in your books : under this head may be classed all 
those cases which are produced by disease of the spinal marrow, its mem- 
branes, the vertebra? or their appendages, their ligaments, and diseases 
directly affecting the great nerves which supply the lower extremities. All 
these matters have been sufficiently studied, and require no additional ob- 
servations from me; my object is to elucidate some of the obscurer varie- 



PARAPLEGIA. 343 

ties of paraplegia. I have touched on this topic before in my lectures de- 
livered at the Meath Hospital, but since that time I have met with many 
cases, and made inquiries which tend still further to illustrate the subject. 
I have read, with the attention which it merits, a lecture on this subject, 
published by my colleague, Dr. Stokes, in Renshaw's London Medical and 
Surgical Journal, and also Mr. Stanley's interesting cases in the 18th vo- 
lume of the Medico-Chirurgical Transactions, published in the year 1833. 
In Mr. Stanley's paper, several cases of paraplegia are brought forward, 
the explanation of which had not been understood before or even at the 
time he wrote, but which I had given several months previously, as ap- 
plied to paralysis in general, in two lectures in the 58th and 59th numbers 
of the London Medical and Surgical Journal, and which had been delivered 
at the Meath Hospital, in Nov. 1832, and were published immediately 
afterwards. In fact, the explanation offered by Mr. Stanley is merely a 
corollary of the propositions which I laid down at that time, and which I 
shall beg leave to repeat here. 

Before I commenced my investigations on the subject, pathologists, in 
endeavouring to ascertain the causes of paralysis, sought for the sources 
of the disease almost solely in the centres of the nervous system. They 
looked for the cause of paralysis in the brain or spinal cord, where they 
supposed it originated either in organic or functional derangement of these 
important organs. In the lectures to which I have already referred, I 
showed that this mode of accounting for all forms of paralysis, by referring 
them to original disease of the nervous centres, was in many instances in- 
correct, and proved, 1 think, to the satisfaction of the class, and those who 
read the lectures, that a most important and influential cause of paralysis 
has been hitherto nearly overlooked — a cause which, commencing its ope- 
ration on the extremities, and not on the centres of the nervous system, 
might, by a reflex action, produce very remarkable effects on distant parts. 
I brought forward on that occasion many arguments, facts, and cases, to 
prove the possibility of such an occurrence — to show that it frequently 
happens that impressions made on the extremities of the nerves will gene- 
rate a morbid action in them ; that this morbid action will be conveyed 
along their branches and trunks to the spinal cord or brain; and that, con- 
tinuing its propagation, it may, by a retrograde course, be carried thence 
along the nerves to distant organs, and in this way give rise to disease in 
parts originally intact and healthy. I brought forward several instances 
to prove that, when a certain portion of the extreme branches of the ner- 
vous tree has suffered an injury, the lesion is not confined merely to the 
part injured, but in many instances is propagated back towards the ner- 
vous centres; and that, in this way, not only the nervous filaments of the 
injured part may be affected, but also the main trunk of the nerve and 
other branches, or that the lesion may reach the brain or spinal cord, and 
thus produce still more extensive effects on the system. What I endea- 
voured to impress upon the class at that time was, that pain, numbness, 
spasm, and loss of the power of muscular motion, may be produced by 
causes acting on the extremities of the nerves ; and that such affections, 
commencing in the extremities of the nerves, may be propagated towards 
their centres so as to be finally confounded with diseases originating in 
the centres themselves. For a detailed account of my views on this sub- 
ject, I beg leave to refer to the published lectures; at present I shall con- 
tent myself with recapitulating a few of the facts on which these views 
were grounded. 



344 CLINICAL MEDICINE. 

If you place your hand in snow or ice-cold water, you will find that 
it is not merely the parts subjected to the influence of cold that become 
numb, and that the diminution of power is not entirely limited to the 
muscles concerned in the peculiar motions of the fingers, but extends 
also to those of the fore-arm, by which the principal motions of the hand 
are performed. Here the impression of cold is found to affect not only 
the parts immediately exposed to it, but also parts that are quite removed 
from its influence and warmly covered. We see that not only the muscles 
attached to the fingers, but also those of the fore-arm, undergo from this 
cause a temporary paralysis. Now, if a cause of a trifling nature, and 
acting only for a time, can, when applied to a part, produce loss of 
power in another and more central part, we may infer that the same cause 
acting permanently might produce permanent paralysis of the latter. We 
can, therefore, conceive how in this case the agency of cold might travel 
upwards and reach the muscles of the arm also, and thus we should have 
a change, commencing in the tips of the fingers, propagated to parts at a 
considerable distance from the situation of the original lesion. Again, 
we find that an injury, affecting one branch of a nerve, will be propagated 
by a retrograde action so as to affect another and distinct branch, as was 
exemplified in a case mentioned in my former lectures on paralysis. A 
young lady, having wounded the inside of her ring finger with a blunt 
needle, observed that she had, in consequence of the injury, a consider- 
able degree of numbness, not only in the wounded finger, but also in the 
little finger next to it. Here we find that an impression made on the 
nerve of one finger not only affects that finger, but also travels backwards 
so as to operate on the branch given off by the ulnar nerve to supply the 
little finger — and given off, observe, above the place of the wound — so that 
the phenomena were identical with those which would arise from an 
injury inflicted on the branch which supplied both fingers. Within this 
last month, I have had an opportunity of witnessing a very striking fact 
of this nature. A young gentleman, distinguished for the extent of his 
classical and mathematical acquirements, and who had just succeeded in 
obtaining the senior moderatorship (analogous to the wranglership of the 
English universities), swallowed a small but angular piece of chicken-bone. 
It lodged low down in the oesophagus, and was not pushed, by means of 
a probang, into the stomach until after the lapse of more than an hour. 
Considerable inflammation of the pharynx, oesophagus, and surrounding 
tissues was the consequence ; on the third day of his illness he got a 
violent, long-continued, and ague-like rigor, which terminated in a profuse 
perspiration, and ushered in a well-marked inflammation of the neck of 
the bladder. In the next place, we find that impressions affecting the 
frontal branches of the fifth nerve may, by a reflex action, operate on the 
retina so as to cause blindness. Here the morbid action travels from the 
circumference towards the centre, and is again reflected towards the cir- 
cumference so as to affect a separate and distinct part. Of this I lately saw a 
curious and instructive example. A medical student, travelling through 
Wales on the outside of the mail, was exposed for many hours to a keen 
north-easterly wind blowing directly in his face. When he arrived at the 
end of his journey, he found that his vision was impaired, and that every 
thing seemed as if he was looking through a gauze veil. There was no 
headache, no symptom of indigestion, to account for this evidently slight 
degree of amaurosis, and yet he was recommended to use cupping to the nape 



PARAPLEGIA. 345 

of the neck, and strong purgatives. When he consulted me, which he 
did in the course of a few days afterwards, I at once saw that there was 
something unusual in the case ; and, after a careful examination, I at 
length elicited from him the fact of his having been exposed to the influ- 
ence of the cold wind. It was now apparent that the retina suffered in 
consequence of an impression made on the facial branches of the fifth 
pair. The cure was effected, not by a treatment directed to relieve 
cerebral congestion, but by stimulation of the skin of the face, forehead, 
temples, &c. 

It is, however, unnecessary to multiply examples to prove the truth of 
the proposition, that disease may commence in one portion of the nervous 
extremities and be propagated towards the centre, and hence, by a reflex 
action, to other and distant parts. Bearing this in mind, we can explain 
why it is that disease commencing in one part of the system may 
produce morbid action in another and distinct part ; and it certainly 
appears strange, that, with so many striking examples before them, pa- 
thologists should have so long overlooked this cause, when seeking to 
explain the nature of many forms of paralysis. If certain irritations of 
the nervous extremities in one part of the body are capable of giving rise 
to a derangement in the whole system of voluntary muscles ; if a local 
affection may become the cause of exalting and rendering irregular the 
functions of every muscle in the body ; then, surely, it is not difficult to 
conceive that a cause, local as the former, and tending not to exalt but 
to depress the motor function of the muscles, may likewise affect not 
merely the nerves and muscles of the part, but also those of the whole 
body, or of distant organs, giving rise to paralysis. Now, pathologists 
have long recognized the fact, that general muscular excitement and 
spasm may arise from the operation of a local irritation. A man gets a 
contused wound on his thumb, or one of his fingers, and some superficial 
nerves are injured. In the course of a few days he begins to feel a 
degree of stiffness about the lower jaw and muscles of the neck, accom- 
panied by a sense of constriction about the diaphragm. This increases 
gradually, all the voluntary muscles are thrown into a state of fixed 
spasm, and he gets tetanus. Here a few trifling branches of the digital 
nerves are injured, the morbid action is conveyed from them along the 
nerves of the arm to the spinal cord and brain, and is thence, by a reflex 
action, propagated all over the body. A wound in the finger causes a 
morbid action in its nerves, and it has been acknowledged by pathologists, 
that this, by acting on the brain and spinal cord, may give rise to a 
general morbid action of the muscular system. This being the case, there 
is nothing improbable in supposing that a cause affecting any portion of 
the branches of the nervous tree, and which produces effects of a paralytic 
nature, may likewise react backwards towards the nervous centres, and 
thence, by a reflex progress, may extend its influence to distant parts of 
the circumference. 

To give another instance: how often do we see irritation, commencing 
in the intestinal mucous membrane, propagated backwards towards the 
brain? Take the familiar example of intestinal worms. A child labours 
under worms ; here the irritation of the digestive mucous surface, whether 
it be produced by the worms, or by the indigestion which accompanies 
them, is propagated from the stomach and bowels to the brain, and thence 
reflected to the voluntary muscles, causing general convulsions. 



346 CLINICAL MEDICINE. 

Dr. William Stokes details the following case in his lectures : " A young 
woman was admitted into one of the surgical wards of the Meath Hospital, 
for some injury of a trivial nature. While in the hospital she got feverish 
symptoms, which were treated with purgatives, consisting of calomel, jalap, 
and the black-bottle, a remedy which deserves the name of coffin bottle, 
perhaps better than the pectoral mixture so liberally dealt out in our dis- 
pensaries as a cure for all cases of pulmonary disease. She was violently 
purged, the symptoms of fever subsided, and she was discharged. A few 
days afterwards, her mother applied to have her re-admitted, and she was 
brought in again, and placed in one of the medical wards. Her state on 
admission was as follows: — She had fever, pain in the head, violent con- 
tractions in the fingers, and alternate contraction and extension of the wrist 
and fore-arm. These muscular spasms were so great, that the strongest 
man could scarcely control the motions of the left fore-arm. In addition 
to these symptoms, she had slight thirst, some diarrhoea, but no abdominal 
tenderness. On this occasion a double plan of treatment was pursued, the 
therapeutic means being directed to the head, in consequence of the marked 
symptoms of local disease of the brain, and to the belly, from the circum- 
stance of abdominal derangement observed in this and herformer illness. 
She died shortly afterwards with violent spasms of the head and fore-arm; 
and as she had presented all the ordinary symptoms of a local inflamma- 
tion of the opposite side of the brain, we naturally looked there first for 
the seat of disease. After a careful examination, however, no percepti- 
ble trace of disease could be found in the substance of the brain, which 
appeared all throughout remarkably healthy. She had all the symptoms 
which, according to Serres and Foville, would indicate disease of the optic 
thalamus or posterior lobe of the opposite side, yet we could not find any 
lesion whatever of its substance, after the most careful examination. But 
on opening the abdomen, we found evident marks of disease; the lower 
third of the ileum, for the length of six or eight inches, was one unbroken 
sheet of recent ulcerations." This case, gentlemen, you will perceive just 
now, bears very strongly on the subject of paraplegia arising from ente- 
ritis. 

Again: how often do we see convulsions brought on in the same way 
by cutaneous irritation? A child gets an attack of fever, accompanied by 
general irritability and restlessness. During the course of the disease, the 
lungs become affected, and the medical attendant applies a large blister, 
which is left on for several hours. Next day the symptoms of nervous ir- 
ritation became more violent ; the child is perfectly restless, or, if it dozes 
for a moment, awakes screaming, and is finally attacked with general con- 
vulsions. Many other examples could be brought to support this view of 
the question, and prove that morbidly increased action of the whole mus- 
cular system may be excited by a cause acting merely on some insulated 
portion of the nervous extremities. i 

I think, therefore, that I am borne out by analogies strikingly exhibited 
by numberless examples, in asserting that the circumference of the nervous 
system has been too much neglected by pathologists in their explanations 
of the nature and causes of paralytic affections. I could give many in- 
stances of pains commencing in particular parts of the body, and travel- 
ling back towards the spine, so as to give rise to an affection of that organ, 
which has been too generally looked upon as the result of idiopathic dis- 
ease. How often does this happen in hysteria? How often does it occur, 



PARAPLEGIA. 347 

that the organ primarily engaged in hysterical cases becomes, during the 
attacks, acutely painful, and as the disease proceeds, the pain travels back 
towards the spine, until at length, the spinal cord itself becomes affected, 
and we find acute pain and tenderness over some portion of its track? I 
am fully persuaded that many modern authors, who have ascribed the phe- 
nomena of hysteria and other affections to spinal irritation, have been too 
hasty and indiscriminate in their explanations. In the majority of cases, 
you will find hysteric patients complain at first, not of pain in any part of 
the spinal cord, but in the right side in the situation of the liver, in the 
region of the heart or stomach, or in the head, or the pelvic region. At 
this period there is seldom any tenderness over the spinal cord ; but, as 
the disease goes on, the irritation which existed in some of those situations 
to which I have referred, is extended to the spine, and pain and tender- 
ness are now felt over some of the spinous processes of the vertebra?. 
When this has taken place, then the spinal irritation thus produced be- 
comes itself a new cause of disease, from which, as a centre, the morbid 
influence is propagated to other organs. The profession owes much to 
Teale, Griffin, and other writers, w T ho have pointed out the importance of 
attending to this spinal tenderness in cases of hysteria, &c. Still, how- 
ever, like all those who have been employed in investigating a new sub- 
ject, they have, perhaps, generalised too hastily, and have, in many cases, 
regarded this spinal tenderness as a cause, when it should have been 
merely considered as a consequence. 

Having thus endeavoured to explain some of the general principles 
which should guide us in the investigation of nervous diseases, I shall 
relate some cases of paraplegia, which, though differing in their origin as 
to the organ inflamed, will strike you as exhibiting a close analogy to 
those published by Mr. Stanley. "In November, 1832, I attended, with 
Mr. Kirby and Mr. Cusack, a young gentleman, aged fourteen, who was 
residing at a boarding-school in the vicinity of Dublin. He had eaten a 
large quantity of nuts on the eve of Allhallows, and had, in consequence, 
obstruction of the bowels, attended with sense of weight and pain of the 
stomach, nausea, loss of appetite, and obstinate constipation. Active 
purgatives, of different kinds, were employed without effect, and the ob- 
struction was only removed by the use of repeated enemata, thrown up 
with Read's syringe, introduced as far into the cavity of the intestine as 
the circumstances of the case permitted. To these means, assisted by 
leeching and stuping, the constipation yielded ; but its removal was fol- 
lowed by symptoms of enteric inflammation, embracing not one, but all 
the coats of the intestine — the mucous, the muscular, and certainly the 
peritoneal. The occurrence of a new and violent disease greatly im- 
peded his cure ; we had a long and anxious attendance, and the young 
gentleman escaped with great difficulty. How T ever, the enteric symptoms 
at length gave way, convalescence became manifestly established, the 
patient was able to sit up in his bed, and as his strength and appetite 
were rapidly returning, he was informed that he might get up. On at- 
tempting to leave his bed, it was found that he had lost the power of 
using his lower extremities — in fact, he had become paraplegic. He had 
perfect power over his arms and trunk, but the lower extremities were 
quite useless. The paralysis, however, was entirely limited to the mus- 
cles ; there was no diminution of sensibility in the limbs ; no numbness, 
pain, or sensation of formication ; and the muscular functions of the blad- 
der and rectum were, apparently, uninjured. 



348 CLINICAL MEDICINE. 

" Before I enter on the explanation of this case, permit me to recite the 
following: — In the month of November last, I was called to visit a lady 
residing in the neighbourhood of Merrion-square, who was said to be 
labouring under symptoms of dyspepsia. She had a sense of weight 
about the stomach, nausea, tendency to vomit, epigastric and hypochon- 
driac tenderness (the latter situated in the right side), but no fever or excite- 
ment of the circulation. In the course of two or three days, she became 
slightly jaundiced, and it was evident that the latent cause of her disease 
was, in all probability, a gastro-duodenitis terminating in an affection of 
the liver. It is sufficient to say, that this lady's symptoms went on, and 
that the diseased action gradually extended to the whole intestinal tube, 
liver, and peritoneum. Her bowels became tympanitic, her belly ex- 
tremely tender on pressure, she got low fever, with quick pulse and great 
restlessness, and w r as saved with difficulty by the repeated application of 
leeches, and the use of calomel, so as to affect the mouth. She became 
convalescent; but with the return of health, it was found that she had 
lost the power of using her lower extremities. She still continues para- 
plegic." 

In the case of the young gentleman already detailed, you will recollect 
that the paralysis was entirely limited to the muscular functions of the 
lower limbs, and that there was no derangement of sensation, no lesion of 
the muscular powers of the rectum and bladder. The same thing occurred 
in this case. There was in the beginning no impairment of sensibility, 
and the power over the rectum and bladder was uninjured. " Within 
the last three weeks, however, she has complained of pain in the loins 
and bowels, and the muscular functions of the bladder are becoming de- 
ranged."* Indeed, the case is rather unfavourable ; it has resisted the 
ordinary remedies, and threatens to become one of confirmed paraplegia. f 
It is to be observed, that in this lady the loss of power was much more 
complete than in the young gentleman before referred to ; his paraplegia 
was by no means perfect, and yielded to the employment of stimulating 
frictions to the extremities, combined with a cautious use of internal sti- 
mulants and tonics. In neither of these cases was the loss of muscular 
power so great as to deprive the patients of the use of their legs while 
lying in bed. They could then be raised, flexed, and extended with ap- 
parent ease and strength ; and yet, when the patient attempted to stand 
up or walk, he was totally unable to do either, his legs sinking under 
him ; and even when supported by a person on each side, so as to take 
the greater part of the weight of the body off the limbs, he was still unable 
to aclvance one foot before another. I cannot understand why so great a 
difference should exist between the muscular force of the legs in the one 
position and in the other. 

Here, you perceive, we have more or less complete loss of power of the 
lower extremities, supervening on inflammation of the gastro-intestinal 
mucous surface. Of this I have now witnessed several examples. How 
are we to account for this? In what way does paraplegia arise from in- 
flammation of the bowels? The mode in which I would explain this 
phenomenon is as follows: — The impression made by inflammatory de- 
rangement on the nervous filaments distributed to the mucous coat of the 

* This sentence was inserted on the 23d March, 1835. Mr. Uarmichael and Dr. Nalty 
have seen this lady repeatedly. 

■j- She began to improve in six months, and eventually quite recovered. 



PARAPLEGIA. 349 

intestines is propagated to the spinal cord, and from this reacts on the 
muscular functions of the lower extremities. It is true that the intestines, 
and most of the abdominal organs, are almost exclusively supplied with 
nerves from the great sympathetic ; but you are to recollect that these 
communicate by numerous branches with the spinal nerves, and that, con- 
sequently, morbid impressions made on their extremities may be rapidly 
and extensively propagated to the spinal cord, and from thence by a reflex 
action to the muscular nerves of the lower extremities. When I first met 
with cases of paraplegia after inflammation of the bowels, or fever with 
gastro-enteric symptoms, I thought that, owing to some peculiarity in the 
case, the great lumbar nerves had become implicated in the disease ; that 
there was an actual inflammatory state of the neurilema, accompanied by 
thickening and effusion, which, by compressing the nervous matter, gave 
rise to the paraplegic symptoms. A more extensive review of the sub- 
ject, however, has convinced me that this is not the fact ; for, if it were, 
the affection of the nerves would naturally be attended with acute pains 
shooting in the direction of their course — for, as far as my experience 
goes, in every instance of inflammation attacking the neurilema, intense 
pain is felt in the parts to which the branches of the affected nerve are 
distributed. Again, though this explanation might apply to cases in 
which the inflammation was general — as where enteric is combined with 
peritoneal inflammation — it would not apply to those cases in which the 
inflammatory action is localised. Thus, in Mr. Stanley's cases, the para- 
plegia supervened on inflammation principally limited to the kidneys. In 
seven cases detailed in Mr. Stanley's paper, we find paralytic symptoms 
produced, not by any derangement commencing in the brain or spinal 
cord, but in consequence of an irritation having its seat and origin in the 
kidneys; and yet, in the majority of his patients, the paraplegia was as 
complete as if it had been produced by idiopathic disease of the cord or 
its investments. What was equally remarkable, many of those cases 
were accompanied by spinal tenderness ; so that the most experienced 
practitioners, on a review of the symptoms, were inclined to look upon 
them as cases of disease affecting the vertebras, or the spinal cord and its 
sheath. Yet on dissection there was no caries of the bones ; no destruc- 
tion of ligaments ; no remarkable vascularity, softening, or suppuration 
of the spinal cord ; no inflammation of its membranes, or effusion into its 
sheath. In almost all, the morbid phenomena were confined to the kid- 
neys ; there were depositions of pus dispersed through their substance, 
and the mucous lining of the infundibula, ureters, and bladder, was thick- 
ened and vascular. The formation of purulent matter was not, however, 
connected with the paraplegia further than as being, like it, produced by 
the same cause — inflammation of the kidney. In one case the paraplegia 
was very complete, and yet the inflammation of the kidney had not ad- 
vanced to the stage of suppuration. 

There can be little doubt that others have frequently noticed the oc- 
currence of paraplegia after inflammation of the bowels, although no 
author has as yet written upon the subject. It is well to be acquainted 
with the occasional occurrence of so untoward and obstinate a sequela of 
enteric inflammation, in order that we may watch attentively the state of 
the lower extremities immediately after the inflammation of the bowels 
has been subdued. As the patient, in such cases, has no pains in his 
limbs, and is not conscious of any loss of power until he attempts to stand 



350 CLINICAL MEDICINE. 

up — and as this attempt is not usually made for many days after the sub- 
sidence of the inflammation of the bowels, in consequence of the great 
debility which the disease and the active treatment necessarily resorted to 
produce — this variety of paraplegia is very liable to be overlooked in its 
commencement, and is thus neglected at the very period when treatment 
is most likely to prove beneficial. The foregoing observations have, no 
doubt, excited a suspicion in the minds of some of you, that the paralysis 
so often observed to follow painter's colic may be derived from a reaction 
of the nervous system of the bowels on that of the muscular system in 
general. Dr. Bright, indeed, has asserted that inflammation of the spinal 
marrow or sheath, as denoted by spinal tenderness, always precedes the 
paralysis produced by lead. It often does, but by no means constantly; 
for I have pointed out to you several cases in this hospital in which not 
the slightest vestige of spinal tenderness could be detected either before 
the commencement, or during the progress, of the paralysis which so often 
follows painter's colic. I am not inclined to adopt the supposition that 
the paralysis in such cases is merely secondary, and the result of the in- 
testinal irritation. I think it much more probable that it depends on the 
poisonous effects of the lead acting directly on the nervoussystem. The 
same observation applies to the paralysis which so often occurs as a result 
of large doses of arsenic. Orfila has remarked that some of the dogs he 
experimented on, and which narrowly escaped dying in consequence of 
large doses of arsenic, became, when they recovered from the immediate 
effects of the poison, permanently paraplegic. I look upon this paralysis 
as a direct consequence of the deleterious action of the arsenic on the 
nervous system, and not as the result of the gastro-enteritis it invariably 
produces. The fact, however, is well worthy of attention, that both 
arsenic and lead produce intestinal irritation in the first instance, and loss 
of muscular power in the second. A knowledge of this fact will prepare 
us for understanding the connection which appears to exist between intes- 
tinal irritation and paralysis. 

In a lecture published by my colleague, Dr. William Stokes, in the 
237th number of the London Medical and Surgical Journal, he makes the 
following observations, which I shall beg leave to quote : — " Here, then, 
we have well-marked paraplegia without any perceptible organic change 
in the spinal cord or its investments, but presenting distinct traces of 
disease in the kidneys. This leads me to observe the very close connec- 
tion which exists between the kidneys and spinal cord — a connection 
which has been long recognized by medical practitioners, but only in a 
limited point of view ; for, though they were of opinion that disease of 
the kidneys and a discharge of ammoniacal urine were the results of 
spinal disease, they never seem to have reflected that the reverse of this 
might happen. It seems, however, now to be almost completely estab- 
lished, that disease of the kidneys may produce symptoms which are 
referable to disease of the spine. Medical men have been too much in the 
habit of looking at this matter only in one point of view. They know 
that disease of the spine will produce disease of the kidneys, and here 
they stop ; but it has been shown that the reverse of this may happen, 
and that renal disease may produce very remarkable lesions in the func- 
tions of the spine. Of this very curious occurrence we have many analo- 
gies in pathology. Thus, for instance, in several cases of cerebral disease, 
but particularly in hydrocephalus, we have vomiting ; here we have 



PARAPLEGIA. 351 

functional disease of the stomach depending on disease of the brain. 
Take the reverse of this, — observe the delirium which attends a case of 
gastro-enteritis ; here you have the functions of the brain deranged in a 
most remarkable manner, and this produced by sympathy with an inflamed 
mucous membrane. The truth is, that in the spine and kidney, as well 
as in various parts of the body, we may have two organs so closely con- 
nected in sympathy, that disease of the one will bring on serious func- 
tional lesion of the other.' 7 

It will be seen tha tthese observations coincide, in many points, with 
the principles I have laid down in the published lectures which I delivered 
on the subject of nervous pathology, and to which I have already referred. 
On this point Mr. Stanley makes the following remarks: — " In reflecting 
on the phenomena of the first series of cases which have been detailed in 
this paper, it might be thought improbable that irritation, commencing in 
the kidney or in the bladder, should be propagated through sentient 
nerves to the spinal cord, and that the impression should thence be trans- 
mitted through both the motive and sentient spinal nerves to the limbs — 
here occasioning an impairment both of sensation and the power of motion. 
Some illustration of this subject seems to be furnished by the researches 
of experimental physiology. If, in an animal, " a few seconds after it has 
been deprived of life, the spinal cord be then divided in the middle of the 
neck, and again in the middle of the back, upon irritating a sentient organ 
connected with either isolated segment, muscular action is produced — that 
is to say , a sentient organ is excited — and an in itation is propagated through 
the sentient nerre to the isolated segment of the spinal marrow, where it 
gives rise to some change, which is followed by an impulse along the volun- 
tary nerves to the muscles of the part."* In the instances which have been 
adduced, irritation, commencing in the nerves of an internal organ — the kid- 
ney — has been transmitted through the spinal cord to the motive and sen- 
tient nerves of the lower extremities ; but the same phenomena may occur 
in an opposite order, as in the case of a compound fracture or other severe 
injury of the lower extremity, followed by retention of urine from irritation 
arising in the anterior and crural ischiatic nerves, and communicated through 
the lumbar and sacral plexuses of spinal nerves to the nerves of the bladder. 
Extending these views to cases of neuralgia where there is no visible de- 
rangement of structure or other local cause of excitement, it will always be 
difficult to determine whether the source of irritation be in the affected 
nerves, or in the central portion of the nervous system whence they are 
derived." 

You will perceive that this explanation, as far as it goes, though not in 
the same words, is in meaning the same as that which I have given, with 
this exception — that it is only a corollary of the general principles which 
I had laid down in my lectures on the pathology of the nervous system. 
Long before the publication of Mr. Stanley's paper, I had established the 
proposition that impressions made upon any portion of the nervous extrem- 
ities may be propagated towards their centres, and thence by a reflex 
action transmitted to the nerves of other and distant parts, so as to give 
rise to morbid phenomena analogous to those which are produced by 
disease originating in the central parts themselves. Applying this prin- 
ciple to the subject of paraplegia, we shall find that, independently of 
cerebral or spinal disease, it may arise from a variety of causes, each 
referable to lesions commencing in distinct and isolated portions of the 

* Outlines of Human Physiology, by H. Mayo. 



352 CLINICAL MEDICINE. 

nervous extremities. Thus, in Mr. Stanley's cases, the exciting cause 
seems to have originated in the urinary system ; in the cases which I have 
detailed, where it supervened on inflammation of the bowels, it com- 
menced in the digestive (and it appears, from a communication made to 
Mr. Stanley by Mr. Hunt, of Dartmouth, that the same thing may result 
from irritation existing in the uterine) system. Mr. Hunt alludes to 
several cases of disease of the uterus being followed by such loss of 
power in the lower limbs, that the patients were entirely confined to bed ; 
adding that there was no change of structure in the parts to which the 
symptoms referred as the source of irritation. In addition to these, I 
shall in my next lecture bring forward several cases to prove that a similar 
loss of power may be produced by the action of cold on the lower ex- 
tremities. Indeed, the number of cases which I have recently met with, 
where paraplegia was evidently brought on by exposing the lower 
extremities to cold and wet, has very strongly directed my attention to 
this form of the disease ; and I trust I shall be able, at our next meeting, 
to communicate some very interesting matter on the subject. 

I shall conclude this lecture by reading the following case, for which I 
have been indebted to the kindness of my friend Dr. Huttori. 

" Richard M'Nab, a sailor, aged thirty-eight, was admitted into the 
Richmond Hospital on the 16th of January, 1835, and placed under Dr. 
Hutton's care. His previous history was briefly as follows : — In the sum- 
mer of 1826 he strained his back in leaping, and was confined to bed in 
consequence of the accident, but recovered in about twelve days. Shortly 
afterwards he contracted gonorrhoea, w r hich was attended with hernia hu- 
moralis ; this yielded to repeated local bleeding, but a gleet remained, 
and this, after continuing for some time, disappeared under the use of 
sea-bathing. He then enjoyed good health, with the exception of occa- 
sional slight pain in the lumbar region, until October, 1830, when, being 
much exposed to cold and wet during along and fatiguing voyage, he got 
an attack of piles, for which he was under medical treatment for seven 
months. During the continuance of this affection, he first observed a fre- 
quency in micturition, but had no retention or sensible obstruction of 
urine. After recovering from the hemorrhoidal attack, he enjoyed good 
health until September, 1834, when, coming from Cadiz to the port of 
Dublin in a very leaky vessel, he suffered greatly from cold, wet, and 
fatigue — being almost constantly engaged at the pumps, which could not 
be left for ten minutes at a time. In addition to this, being deprived of 
his usual allowance of spirits for thirty-two days, he found himself, on his 
arrival in Dublin, in a very weak state. He rested from his occupation 
for a fortnight after discharging his cargo, and states that during this time 
he drank from four to six glasses of whiskey daily. He then went on 
board the Elizabeth, of London, as chief mate, but after eight or nine 
days his back and lower extremities became affected with pain and weak- 
ness, which increased to such a degree that he w T as obliged to give up his 
occupation on the thirteenth day. He states that, during the time his 
back and legs were getting weak, he was obliged to pass water about 
three times in an hour, which he did with pain and tenesmus. On the 
1st of January Ihe pain of his back was very severe, and he lost the use 
of his limbs, but not completely, for he could support himself, and even 
walk a little with the aid of two sticks. 

" At the time of his admission he appeared somewhat broken down in 



PARAPLEGIA. 353 

his general health ; he was pale, emaciated, and laboured under derange- 
ment of his digestive organs. He suffered from occasional chills, suc- 
ceeded by heats and sweating, which occurred at irregular periods ; he 
also laboured under micturition, dysuria, and the stream of urine was 
much diminished ; the weakness and loss of power in his lower extremi- 
ties as reported. 

" His treatment was as follows : — first, cupping over the loins, then 
moxae in the same situation ; attention to his digestive organs; diluents 
and opiates for the urethral symptoms. On the 26th of the same month, 
a very close stricture was found to exist in the membranous portion of the 
urethra. A small catgut bougie of double length was introduced, so that 
one-half of it projected from the meatus ; over this was slided a small 
gum-elastic catheter of ordinary length, and open at each end, until it 
traversed the stricture and reached the bladder ; the catgut bougie was 
then withdrawn, and the gum-elastic catheter secured. A little consti- 
tutional disturbance followed, but soon subsided, and in a few days gum- 
elastic catheters of a much increased size were introduced with facility. 

" A very remarkable amendment took place in his back and lower ex- 
tremities, in a very few days after the first introduction of the instrument ; 
in fact, it was almost sudden. Warm baths, friction to his limbs, &c, 
completed his cure. He was discharged on the 25th of February, at 
which time the power of his lower limbs was perfectly restored, and the 
symptoms affecting the urinary system had disappeared." 

You at once perceive the extreme importance of this case ; it bears 
directly on the question before us, and proves that urethral irritation may, 
as well as inflammation of the kidneys, give rise to paraplegia ; and it 
affords another striking illustration of the general proposition which I have 
laid down. 

In the next class of cases we have to consider, the cause of the paraple- 
gia is extremely obscure — I mean those cases in which the paraplegia oc- 
curs during the course of fever. Here the other sufferings of the patient, 
and his general debility, attract our notice so exclusively, that the para- 
lysis entirely escapes notice until convalescence is established — until, in 
fact, the patient wishes to support himself on his legs. He then finds, 
much to his surprise, that his limbs collapse under him, and that he has 
little or no power over them; this appears to him the more extraordinary 
on account of his having recovered a good deal of strength in his upper 
extremities. Thus, a Miss F. was attacked with fever, while on a visit to 
a friend in Dublin. She was attended by Mr. Carmichael. Her fever 
was protracted and severe, and exhibited, during its progress, well-marked 
symptoms of gastro-intestinal irritation and congestion, viz., tympanitis, 
epigastric and abdominal tenderness, &c. When her convalescence was 
established, her attendants found, to their great alarm, that she had no 
power in her legs. She complained of coldness and numbness in the lower 
extremities. This lady gradually recovered the use of her legs, but not 
until moxse, without number, had been applied along the course of the 
spinal column. The cure lasted about a year. No evidence could at any 
time be detected, indicating disease of the spinal bones or ligaments. Mr. 
Carmichael has seen several cases of paraplegia following the remittent 
gastric fever of children, totally unconnected with spinal disease. Such 
an occurrence is most usual in children of a scrofulous temperament, and 
is seldom, very seldom, remedied either by time or medicine. Two ex- 
24 



354 CLINICAL MEDICINE. 

planations suggest themselves as capable of accounting for the paraplegia 
after fever. The first rests upon the frequency of the occurrence of vio- 
lent pain in the small of the back in the commencement of this disease. 
This pain in the back is often excruciating, and generally accompanied by 
proportionally violent pains in the lower extremities. I am quite as anx- 
ious to relieve the pain in the back in the beginning of fever, as I am to 
remove headache ; one is almost as serious as the other, for the vital im- 
portance of the spinal marrow in the economy is scarcely less than that of 
the brain. 

In reference to this point of practice, I have been in the habit of using 
the expression (in order to fix the attention of my pupils), that such a pa- 
tient has not any pain in his head, but he has gotten his headache in the 
small of his back. Now, when headache is the prominent feature of the 
first stage of fever, how few will omit bleeding, leeching, cupping, cold 
or hot applications, &c. &c. When, on the contrary, the lumbar spinal 
marrow is the seat of the congestion, how generally do practitioners neg- 
lect the application of topical bleeding, and other appropriate remedies. 
Were such neglect of less frequent occurrence, it is probable that paraple- 
gia after fever would not so often be met with. Some maybe inclined to 
look for the source of the paraplegia which follows fever in the irritation 
of the gastro-intestinal mucous surface, propagated by a reflex progress to 
the spinal marrow. It is not easy to decide between these two explana- 
tions, but I confess myself more inclined to adopt the former than the 
latter. 

I shall now proceed to lay before you some facts and cases illustrating 
the nature of another form of paraplegia, a form of extreme interest, from 
the circumstance of its being hitherto but little understood, and not men- 
tioned by any writer I am acquainted with, as well as from the peculiar 
nature of its origin, and the frequency of its occurrence. I have, within a 
comparatively short period of time, met with several instances of this affec- 
tion, and have some cases of it at present under treatment. 

Before I enter on this part of the subject, I may be allowed to remark 
that, in some cases, loss of the power of motion in a limb can evidently be 
traced to the operation of a cause whose action is confined altogether to 
the surface. Thus, in the case of a woman in Sir P. Dun's Hospital, ery- 
sipelas occupied the calf and inside of the right leg, and occasioned some 
inflammation and tenderness along the chain of lymphatics extending to 
the groin, where one of the inguinal glands was slightly enlarged and pain- 
ful. The erysipelas yielded to the employment of local and general reme- 
dies ; but, for several days, and particularly while the disease was at its 
acme, she was altogether destitute of any power of motion in the affected 
limb ; she could neither bend the leg on the thigh, nor could she raise the 
whole limb. This affection must have been produced by a reflex action 
propagated from the cutaneous branches to the larger muscular nerve,s. It 
is evident, that the muscles which move the leg on the thigh could have 
been affected only in this way, for they lay far above the part in which 
the erysipelatous inflammation existed. It is in the same way that we are 
to account for the paralysis observed in cases of phlegmasia dolens. 

Sometimes the reverse of this happens, and a single limb becomes para- 
lyzed, on account of an injury done to one of its principal nerves by the 
application of sudden violence, or of pressure long continued. Thus, a 
case was related to my friend Dr. Brennan and myself, in which a robust 



PARAPLEGIA. 355 

gentleman having been much fatigued during the day, fell asleep after 
dinner, his head resting on his arms which were crossed on the table. In 
consequence of some unfortunate awkwardness in his position, one of the 
ulnar nerves was compressed during the time he slept, and, on awaking, 
his fore-arm and hand were completely powerless. Many remedies were 
tried in this case without success, and the paralysis continued until the 
day of his death, which occurred several years afterwards. A lady not 
long since, was tripped up in walking across the floor, and fell with con- 
siderable force. Trie parts which sustained the principal shock were the 
left hip and trochanter. From the moment of the accident, she lost all 
power in the left lower extremity, which remained permanently paralytic. 
Fracture or dislocation was suspected at first, but a minute and careful 
examination show T ed that the suspicion was groundless. No injury of the 
spine could be detected, and she had no numbness, pain or formication 
ill the affected limb. After a month she w T as placed under the judicious 
care of Mr. Kirby, who used every topical application likely to prove use- 
ful, but without the slightest benefit. She returned to the country, where 
she died shortly afterwards, quite unexpectedly, in the bloom of life, and 
without the occurrence of a single symptom indicative of approaching 
danger. No autopsy was permitted. 

I shall now, with the view of illustrating the form of paraplegia to 
which I have alluded, read the following very remarkable case, which I 
had an opportunity of tracing through all its stages, and which made a 
very considerable impression on me at the time. The history is chiefly 
derived from notes furnished by the patient himself before he became too 
weak to write : what relates to the latter stages of his complaint is taken 
from my own case-book. 

Mr. B., aged twenty-three, was remarkably strong and healthy, though 
of a spare habit. He was able to take a great deal of exercise, capable of 
enduring much fatigue, and passionately fond of hunting, fishing, and 
shooting, particularly the latter ; and, in pursuit of his favourite amuse- 
ments, frequently exposed himself to wet feet during his excursions 
through bog lands, and when wading in the water. These habits, how- 
ever, he laid aside after the occurrence of the first attack of his illness, 
which happened in 1829. He had for many years been of a costive 
habit, his bowels being frequently confined for a week at a time, but did 
not experience any sensible bad effects from this circumstance, and never 
took any aperient medicine. Since the first attack in January, 1829, this 
state ceased, and his bowels became ever afterwards inclined to looseness, 
which always increased before the appearance of one of the attacks, accom- 
panied by griping, nausea, and inclination to vomit. Each attack was 
generally preceded by a copious secretion of insipid watery fluid in the 
mouth, and then the characteristic symptoms of his disease commenced. 
These consisted in obstinate and protracted nausea and vomiting; he first 
threw up whatever happened to be on his stomach at the time, and after- 
wards every thing he swallowed, whether solid or liquid. The matter 
ejected was at first acid and afterwards bitter, varying in colour from 
mucous to bilious, but being generally of a greenish and occasionally of a 
bluish tinge. The greenish fluid annoyed him much from its extreme 
bitterness, and the quantity thrown up in the course of the day varied 
from three to four quarts of fluid. He complained also of pain, referred 
to the stomach or lower part of the chest, which continued throughout the 



356 CLINICAL MEDICINE. 

attack, being most acute at its commencement ; for the last year, this 
sensation had passed into a feeling of painful constriction, which he de- 
scribed as a u contracted feeling of his inside," and compared it to some- 
thing like the effects of a cord drawn tightly, so as to compress or stran- 
gulate his body exactly along the outline occupied by the insertions of the 
diaphragm. During the prevalence of the attack, he had profuse perspi- 
rations, particularly towards the termination of each paroxysm. The dura- 
tion of the first attack did not exceed four or five days, after which, he 
became quite well, and continued so for six or seven months, when his 
symptoms suddenly returned. He began to reject every thing from his 
stomach as before, but in the course of a few days the vomiting disap- 
peared, and for a considerable interval he had no return of his complaint. 
In the year 1830, he had three attacks of a similar description ; from these 
he recovered also completely, and without remarking any diminution of 
power in his lower extremities. In 1831, however, the disease began to 
assume a more serious aspect ; the paroxysms became much increased in 
severity, lasted longer and recurred at shorter intervals. For one of these 
attacks he took mercury, and was salivated. In 1832, his symptoms be- 
came still more violent, and the duration of the paroxysms more pro- 
tracted. He had one in March, a second in May, and a third in June, 
each of which was accompanied by some numbness and loss of power in 
the lower extremities ; this, however, was slight, and disappeared alto- 
gether as the vomiting subsided. About this time, he noticed that his 
urine was scanty, and deposited more sediment than usual. He also com- 
plained of being very apt to catch cold whenever he got out of bed, and 
stated that he suffered occasionally from severe twitches and pains in his 
legs, thighs, arms, and other parts of his body, which were generally 
succeeded, and carried off, by profuse perspirations. 

In August, 1832, he had a violent attack, which lasted nearly a month. 
The vomiting was incessant, continuing night and day, and he suffered 
severely from the feeling of painful constriction already described. On 
getting up after this attack, his legs suddenly failed him, and he dropped 
down on the floor quite powerless. The paralysis did not now disappear 
during the intervals, although it grew somew T hat better after each fit of 
vomiting had ceased ; indeed, he used to improve in his walking after 
the paroxysm had entirely disappeared ; and, aided by two sticks, sup- 
ported himself so as to give some hopes of a recovery until a recurrence 
of his attack reduced him again to a state of almost total paraplegia. His 
legs now began to waste sensibly, and he noticed that they had lost their 
feeling and were remarkably cold. He also complained of severe twitches 
of pain in various parts of his body, accompanied by profuse night-sweats, 
and turbid, scanty urine. 

For some months before his death he was completely paraplegic, and 
continued to be attacked with violent fits of vomiting. The vomiting 
went on night and day, and he was unable to retain the mildest and 
most soothing substances for a moment on his stomach. Mr. Crampton 
and Dr. Ireland attended him w r ith me, and we had recourse to every 
thing we could think of to allay the irritability of his stomach, but in 
vain. After continuing to resist obstinately every form of treatment for 
five or six days and nights, the vomiting would suddenly cease, the gen- 
tleman would exclaim, "Now I am well," and he could then eat, with 
perfect impunity, substances which would prove irritating and indigesti- 



PARAPLEGIA. 357 

ble to many stomachs. This was one of the most singular circumstances 
I ever witnessed. The transition from a state of deadly nausea and 
obstinate retching to a sharp feeling of hunger, used to occur quite sud- 
denly. One hour he was the most miserable object you- could behold, 
racked with painful constrictions across the epigastrium, alternately 
flushed or bathed with cold perspiration, and rejecting every thing from 
his stomach, the next found him eating with a voracious appetite what- 
ever he could lay hold of, and digesting every thing with apparent 
facility. 

It may be observed that as the disease in this case proceeded, the 
intervals between the attacks diminished, while the paroxysms increased 
in duration. For the first two years they continued only for four or five 
days, and appeared at intervals of six or seven months ; latterly they used 
to last for eight or ten days, and returned every third or fourth week. 
During the paroxysm the only thing which he took was a little cold water 
with some brandy and a few drops of laudanum, which remained longer 
on his stomach than any thing else, and enabled him to enjoy a few 
minutes sleep. He never complained of any headache, and his intellect 
was remarkably clear, and his memory good. 

No trace of organic disease could be detected in the abdominal viscera, 
and there was not the slightest tenderness over any part of the spine. 
He also retained to the last a complete power over the bladder and 
rectum. 

At length his system began to give way ; long confinement to bed, and 
the frequent recurrence of these exhausting attacks completely wore hirn 
out, and he sank on the 30th September, 1833. A post-mortem exami- 
nation was allowed by his friends, and we scrutinised every part of his 
system with the most anxious care. The brain, cerebellum, spinal cord, 
and their investing membranes, were carefully inspected ; we examined 
the large nervous trunks that supply the lower extremities, inspected the 
viscera of the thorax, and searched for evidences of disease in the stomach 
and intestinal tube; we could find none. There was no lesion of the 
brain or spinal cord, no thickening or vascularity of membranes, the large 
nerves exhibited their normal condition, the stomach was perfectly healthy, 
the intestinal canal natural, the liver and other glandular viscera of the 
abdomen without any trace of appreciable derangement. 

Here, then, was a case of perfect paraplegia (I say perfect, for he had 
lost all power of his lower extremities for more than two months before 
his death) which may be fairly termed functional, inasmuch as there was 
no lesion of any part of the nervous centres to explain the phenomena 
present. How then are we to account for them ? the first symptoms were 
undoubtedly those of abdominal irritation, as manifested by the tendency 
to diarrhoea in an originally costive habit, accompanied by violent 
paroxysms of vomiting which recurred at distant intervals. Are we to 
attribute this diseased condition of the stomach and bowels, which, from 
the remarkable periodicity of its occurrence, was evidently functional, to 
irritation, congestion or inflammation of the brain or spinal marrow? 
From the data we are in possession of, it appears that this question must 
be answered in the negative. There was no headache, heat of scalp, 
throbbing of the temporal arteries, or other sign of determination to the 
head, of congestion, or inflammation of the brain either before or during 
the attacks. The patient's intellect was all throughout remarkably clear, 



358 CLINICAL MEDICINE. 

and his memory good. Again, if we look for the origin of the disease in 
the spinal cord or its investments, we can find nothing to assist in ex- 
plaining the phenomena. There was no pain in any portion of the spinal 
cord, and at no period of his illness could we detect any tenderness over 
the spinous processes. The history of the case seems to prove that what- 
ever was the cause which operated on the nerves of the stomach and 
intestines, it gradually extended the sphere of its morbid influence to the 
spinal cord, and, through it, implicated the nerves of the lower extremi- 
ties. The case is in many respects highly interesting, and well worthy 
of the attention of the pathological inquirer. The dissection was con- 
ducted in the presence of Dr. Ireland and myself, by my friend and 
former pupil, Mr. Harris, so advantageously known for his skill in 
morbid anatomy. It was not made in a hurried or careless manner, 
each organ w T as carefully examined, and the process occupied at least 
four hours. 

The next case to which I shall call your attention, is one which I have 
already given in a former lecture ; it seems, however, to be so similar in 
the nature of its exciting cause to the foregoing though differing in some 
of its symptoms, that I shall beg leave to repeat it here. 

James Moore, aged 32, was admitted into the Meath Hospital on the 
3d of March, 1833, under Dr. Stokes's care, for an attack of paraplegia, 
which he attributed to cold and w T et feet while engaged in working in a 
quarry. About a month before admission he perceived a stiffness of the 
great toe of his right foot, afterwards numbness and coldness of the sole, 
and then of the leg as far as the knee, and dragging of the limb in walk- 
ing. During the progression of the disease up along the right thigh it 
commenced in the left foot, and after a few days he experienced almost 
complete paralysis of sensation in the right lower extremity, and a lesser 
degree in the left, accompanied by so much diminution of the power of 
motion, as to render him unable to walk without support. About three 
weeks after the appearance of paralysis in the lower extremities, the little 
finger of the right hand was attacked with numbness, which passed suc- 
cessively to the rest, attended by some loss of the sense of touch and 
power of grasping objects. He had also retention of urine, and the bow- 
els were obstinately constipated. There was no tenderness over any 
part of the spine. He had no pain in the head ; his pupils were natural ; 
pulse, sleep, and appetite also normal. 

Here we have an instance of paraplegia apparently originating from an 
impression made on the nerves of the lower extremities. The man had 
been engaged in draining a quarry, and during his occupation was con- 
stantly exposed to wet ; shortly after this he begins to complain of numb- 
ness and loss of power in the right lower extremity, and, during the pro- 
gression of the disease up along the limb, the left becomes similarly en- 
gaged. About three weeks afterwards, the hands, which had been also, 
but not so frequently exposed to the influence of cold and wet, begin to 
be affected with numbness, and the power of grasping objects is dimi- 
nished. To what can we attribute these symptoms, except to the influ- 
ence of cold acting on the nervous filaments of the cutaneous surface of 
the limbs, extending its morbid impression to the spine, and thence re- 
acting on the nerves, so as to produce impairment of the power of motion 
and diminished sensation ? The man certainly had no symptom of cere- 
bral or spinal disease, nor was there any thing connected with the state 



PARAPLEGIA. 359 

of the nervous centres which would lead to the supposition that para- 
plegia was the result of an irritation originally affecting the brain or spinal 
cord. It was on these grounds that I gave it as my opinion at the time, 
that the disease was an example of creeping paralysis, having its origin 
in an affection of the peripheral extremities of the nerves. 

The next case is one which was also under treatment in the Meath 
Hospital during the course of last winter : for the particulars I am in- 
debted to my colleague, Dr. William Stokes. 

A robust, middle-aged man was admitted into the chronic ward of the 
Meath Hospital, in the latter end of February, 1834, labouring under para- 
plegia. He stated that he was generally employed as a boatman about the 
river and port, was frequently exposed to cold and wet, particularly in his 
lower extremities, and that he was in the habit of drinking freely. He 
had enjoyed good health until about seven weeks before admission, when 
he was seized with numbness of the feet and legs, which, after continuing 
for three or four days, was followed by tingling pains running along the 
course of the nerves. He then remarked that the power of his lower ex- 
tremities was much diminished, and this gradually increased so as to pre- 
vent him from walking or even standing without support. His bowels 
became obstinately costive, and about a month after the commencement 
of his attack, he perceived that his urine was discharged in smaller quan- 
tity than usual, and that he w r as much more frequently called on to pass it 
than before. He also mentioned that he had gonorrhoea about six months 
before, and that he had used balsam of copaiba and injections. Some 
time after this he said he noticed some white matter passing with the 
urine, but did not pay any particular attention to it as it gave him no in- 
convenience. His appetite was tolerably good, and he had no headache 
or any symptom of determination of blood to the brain. He denied hav- 
ing received any injury of the back, and there was no tenderness over 
the spinous processes of the vertebrae. He had no pain in the spine, 
either before or since the occurrence of his illness, nor was there any 
symptom of inflammation of the substance or membranes of the spinal 
cord. When admitted he had considerable diminution of sensation and 
complete loss of motion in one of the lower extremities ; in the other he 
still retained some power. He had also retention of urine, requiring the 
daily use of the catheter. 

The treatment was as follows : — He was placed on one of Dr. Arnott's 
hydrostatic beds, as there was a great tendency to stripping over the hips 
and sacrum, a purgative pill was administered two or three times a-day 
to remove the costiveness, and he was ordered to be cupped over the 
loins. The latter was done in consequence of his complaining of some 
tenderness on pressure in the situation of the kidneys. His symptoms, 
however, went on without any improvement, and he died about a month 
after his admission. 

On dissection the following phenomena were observed. The kidneys 
(which were first examined) appeared rather soft, and of a yellowish 
colour, but there was no vascularity, suppuration, or other change of 
structure. The ureters were somewhat distended, but presented no other 
trace of disease. The bladder was contracted, its muscular coat thick- 
ened, and its mucous membrane very vascular. There was no affection 
of the prostate. On examining the spinal cord, Dr. Stokes observed that 
he thought the cauda equina appeared to be slightly softened, but re- 
marked that from its appearance he could not state that it was actually 



360 CLINICAL MEDICINE. 

diseased. The rest of the spinal cord appeared healthy and normal ; 
there was no vascularity, effusion, or softening. External to the sheath 
of the cord there was a small, flattened, oval body, about the size of half 
a very small hazel-nut, and of a consistence intermediate between lymph 
and fat. Around this there was some slight degree of vascularity. Dr. 
Stokes observed, that from the small size of this body, and the peculiarity 
of its texture, he entertained strong doubts as to its having any influence 
in the production of the symptoms noticed during life. He remarked, 
although it might have been originally the product of inflammation, and 
have existed in the form of an effusion of lymph, still the circumstance of 
its conversion into a fatty substance proved that it must have existed for 
a very considerable time, and the smallness of its size, as well as the ob- 
scurity of its origin, did not by any means satisfactorily explain the oc- 
currence of paraplegic symptoms. 

The next case which I have to lay before you, appears to be analogous 
in its mode of origin to the former: — "A gentleman of strong constitu- 
tion, and extremely fond of field sports, particularly fishing and shooting, 
exposed himself repeatedly to wet feet at a time when he was labouring 
under the effects of a long mercurial course. Taking large quantities of 
blue pill, and exposing the lower extremities to wet at the same time, are 
circumstances which have an obvious tendency to produce disease, and 
it is not to be wondered if this gentleman became the victim of his want 
of caution. He got numbness and weakness in his legs, which he at 
first attributed to fatigue and over-exertion ; but as the disease went on, 
he became more and more powerless, and, finally, applied to me respect- 
ing his illness. On examination I found that he had no pain in the back, 
or tenderness on pressure; nothing, in fact, to indicate any original affec- 
tion of the spinal cord. The functions of the brain also were natural, 
and there was nothing about him to lead me to suspect cerebral disease. 
He had, however, considerable impairment of the muscular functions of 
the lower extremities, and could not walk without the aid of crutches, or 
some person to support him. In treating this case, I looked upon it as 
an instance of imperfect paraplegia, in which the paralysis apparently rose 
from impressions made upon the sentient extremities of the nerves of the 
legs and feet, at a time when these nerves were particularly liable to be 
deranged in their functions from the previous use of mercury. I there- 
fore had recourse to remedies directly applied to the extremities of those 
nerves, and fortunately succeeded in restoring this gentleman to the use 
of his limbs. The cure, however, was not perfect, for a very notable de- 
gree of weakness still remains. 

Of this form of paraplegia I have now witnessed many instances. In 
most cases I was induced to think that it arose from impressions made by 
cold and wet on the lower extremities. It is most commonly observed in 
young gentlemen who are addicted to fishing and shooting, and who in 
pursuit of their amusements get wet feet repeatedly, from walking over 
boggy grounds, or wading in the water. It is also observed in labourers 
whose employment obliges them to stand in water for many hours together, 
as in draining, pump-sinking, and other similar occupations. In all cases 
it assumes the creeping form, and generally appears at first in one limb, 
and afterwards in the other. There is, however, considerable variety in 
the rate of its progress ; in some cases the patients become almost com- 
pletely paraplegic in a few weeks from the commencement of the disease, 
in others it will go on for months, and even years, before the power of 



PARAPLEGIA. 361 

the lower extremities is completely destroyed. Where its progress is slow, 
it makes its approach in an insidious manner, and is at first scarcely 
noticed by the patient. Its latency is here further favoured by the absence 
of pain, numbness, or formication; for it is only at the more advanced 
stages of such cases that derangement or diminution of sensation is noticed. 
It is only when making some unusual exertion, as in going up stairs or 
ascending a hill, that the patient finds a more than ordinary degree of 
weakness in the lower extremities. The first symptom which generally 
attracts his attention, is an incapability of walking as far as he has been 
accustomed, but this is attributed to some temporary weakness, or is con- 
sidered to be the result of previous fatigue. As the disease progresses, 
walking up an ascent becomes a matter of some difficulty, there is a 
shuffling motion of the legs, and the patient is apt to stumble from slight 
obstructions. Gradually the loss of power becomes more manifest, it ex- 
cites the attention and surprise of the patient, and he finds that he is no 
longer able to walk without the aid of a stick or some person to lean on. 
The paralysis is, however, seldom complete ; with the help of crutches 
the patient continues to hobble about, and it is only in bad cases, and at 
an advanced period of the disease, that he becomes completely paraplegic. 
The paralysis is never so sudden nor so complete in this form of paraple- 
gia, as it is in cases of disease of the spinal cord, or scrofulous ulceration 
of the bones and ligaments. 

In other cases, however, the paraplegia, though evidently of the same 
origin, and having the same creeping character, advances with much 
more rapidity ; and the patient may, in a few weeks from the commence- 
ment of the attack, experience a very considerable diminution of power 
in the lower extremities. In such cases it will be generally found that 
one limb is much more affected than the other, the loss of power being 
most complete in the limb which was first engaged. 

With respect to sensation, it appears to be affected as well as motion. 
In the slow and chronic form of this species of paraplegia, it does not 
attract the attention of the patient so quickly as the derangement of mus- 
cular power ; it is generally some time before he notices any diminution 
of sensation, and then accidentally. In the more advanced stage, how- 
ever, this becomes manifest, and is accompanied by a feeling of cold in 
the lower limbs, which seldom extends higher than the knees. In the 
more rapid and acute form, the derangement of sensation is much more 
obvious, and is generally the first symptom noticed by the patient. There 
is at first a feeling of numbness, which commences in the toes or feet, and 
extends up the limb : this, in the course of a few days, is followed by 
formication and tingling pains in the course of the nerves, and then loss 
of power and diminished sensation. There is, however, in both these forms 
of paraplegia, much less impairment of sensation than of motion, and the 
loss of sensation is never so complete as in paraplegia from disease of the 
spine. 

There is one curious symptom occasionally observed in this disease, 
which is that, before the appearance of any decided symptoms of loss of 
power in the lower extremity, irritation of the lower part of the digestive 
tube takes place ; the rectum becomes morbidly excited ; the patient 
complains of tenesmus, and thinks he is about having an attack of piles. 
This was the first symptom observed in one of the cases I attended ; the 
patient complained so much that we were induced to examine the state 
of the rectum, but could not find any thing to account for the morbid ex- 



362 CLINICAL MEDICINE. 

citement. The same observations apply to the bladder, with this excep- 
tion, that the morbid irritability of this organ occurs occasionally after the 
disease is confirmed and has made considerable progress. On the whole, 
however, affections of the bladder and rectum are rare in this form of 
paraplegia ; and it is only at the advanced stages that we sometimes meet 
with that derangement in the muscular powers of the bladder and rectum, 
which occurs so frequently, and at such an early period, in the paraplegia 
from spinal disease. 

In cases of paraplegia from disease of the spinal cord or its investments, 
it has been observed that the urine becomes altered in its quality, and 
assumes an ammoniacal odour. I have not observed this occurrence in 
the forms of paraplegia that I have detailed. The urine is turbid, scanty, 
and voided oftener than usual ; but I cannot say that I have seen it in 
any case decidedly ammoniacal, even in the advanced stages of the dis- 
ease, and where the patient was completely bed-ridden. Should future 
observations prove that this diagnostic mark is constant, it may be of 
some value in distinguishing this from other forms of paraplegia. 

Jn these cases there is scarcely any thing which would lead us to fix on 
the spine as the seat and origin of the disease ; neither can we find any 
thing in the brain with which we can connect the paraplegic symptoms. 
There is no pain of the head or spine, very seldom any tenderness, the 
patients are in the full vigour of intellect, and all the organs of sense in 
their normal condition. The functions of respiration and circulation are 
unaffected ; and it was remarked in the first case which I have detailed, 
that there was no change in the pulse, either during the fits of vomiting, 
or the intervals of ease. The appetite also is generally good ; but, in 
almost every instance I have met with, there has been remarkably obsti- 
nate constipation. 

With respect to the prognosis and treatment of this form of paraplegia, 
I have but little to say. The prognosis is generally unfavourable, particu- 
larly where the disease has lasted for some time, and is accompanied by 
morbid irritation, or loss of power in the bladder or rectum. It is also 
bad in proportion to the slowness with which it has come on, and the 
absence of pain or formication of the lower extremities. With respect to 
treatment, I may observe that I have never seen any benefit derived from 
applications to the spine. The application of blisters or issues over the 
back or loins, does not appear to be productive of the least good effect ; 
of the latter, I can speak positively, from experience. They are an en- 
during source of annoyance to the patient, and never produce the least 
amelioration of symptoms. I am in the habit of applying my local reme- 
dies to the legs and thighs, selecting those parts in which the greatest 
cutaneous sensibility exists. What I generally do, is to keep up a suc- 
cession of blisters along the inside of the legs, and over the anterior and 
inner parts of the thighs. The practice of medicine furnishes many proofs 
of the utility of stimulant applications to the nervous branches, in case of 
disease affecting the larger trunks. Thus, in sciatica, a blister, applied 
over the ham or calf of the leg, where many of the ultimate ramifications 
of that nerve are superficial, will frequently produce a much more decided 
effect than when applied over the origin of the nerve itself. Liniments of 
a stimulating kind, and blisters repeatedly applied, are the local means 
on which I chiefly rely in the treatment of this form of paraplegia. After 
some time, I commence with the use of strychnine, and continue it until 



ELECTRO-MAGNETISM. 363 

some sensible effect on the system is produced, when I omit its further 
use, and have recourse to the exhibition of sulphur. These are the two 
internal remedies from which I have derived most benefit. I have in 
such cases seen very good effects from a perseverance in the use of the 
sulphur electuary, of which I have given a formula in one of my pub- 
lished lectures. Much also will be accomplished by the external use of 
sulphur, in the form of baths, and hence cases of paraplegia of this kind 
might be materially benefited by the internal and external use of the 
waters of Lucan, Harrogate, Baden, Barege, &c. With respect to the use 
of mercury, it appears to be decidedly injurious. I have seen it given in 
three cases ; in all it did much more harm than good. 

This is all I have to say at present on the subject of paraplegia. I 
fear much that many omissions, and considerable deficiency of materials, 
will be observed in the statements I have laid before you. I hope, on 
some future occasion, to be able to communicate a more minute and better 
digested series of observations on this obscure form of disease. The sub- 
ject, however, is in itself so interesting, and so important, that I have 
been tempted to bring it before you, perhaps prematurely. My anxiety 
to excite discussion, and attract further attention to a department of prac- 
tical medicine hitherto quite neglected, must on this occasion plead my 
excuse. 



ELECTRO-MAGNETISM. 
LECTURE XXXIII. 



As Mr. Clarke has lately been employing electro-magnetism very suc- 
cessfully in my wards at the Meath Hospital, I have obtained from him 
notes of some of the cases, and also an account of his apparatus, &c. 
This document I feel great pleasure in laying before the reader. 

rt Brief notes of some cases in which I have applied Electricity to patients in 

the Meath Hospital. 

" Edward Fitzgerald, labourer, admitted 24th April, 1842 — discharged 
cured 5th June, aged 50 — temperament sanguineous. Disease — lumbar 
rheumatism, extending to the pelvis ; also sciatica. Felt much stiffness 
of the loins, and pain when walking, and particularly when attempting to 
stoop. Attributed his complaint to watching in the open air at night. 
Had been cupped and blistered without effect. 

" Applied magnetic electricity four times, from 20th to 23d of May 
inclusive, by which time a perfect cure was obtained. Remained in hos- 
pital until 5th June, without experiencing any return of the disease. 

" Edward Kelly, labourer, aged 40, admitted 12th May, 1842, — dis- 
charged, much relieved, on the 28th June — temperament bilious. Dis- 
ease — chronic rheumatism, with enlargement anterior and inferior to the 
malleoli of each foot, accompanied with some erfusion into the adjacent 
parts. Had suffered under this disease during the entire of the past four 
years, having been treated in other hospitals and discharged uncured ; 



364 CLINICAL MEDICINE. 

and since his admission into this hospital, had been blistered, leeched, and 
treated with hydriodate of potash and colchicum, without much benefit. 

" I applied electro-magnetism for about ten successive days, and suc- 
ceeded in reducing the enlargement below the ankles considerably, and 
enabling him to walk well ; still, after much exercise, a disposition of the 
same part to swelling existed, and we cannot, therefore, say, that a per- 
fect cure was effected, even under the combined treatment of medicine 
and electro-magnetism. And as so much other treatment was adopted, not 
electrical, I did not deem this a case deserving of long-continued perse- 
verance, more particularly as I conceived it likely that he would not be 
permanently restored by any treatment whatever. 

" Anne Cummins, admitted 17th May, 1842 — discharged cured on 1st 
July — temperament changing from sanguineous to nervous. Diseases — 
ptosis of right eyelid; amaurosis, which had deprived right eye of vision, 
and so injured the left, that she could hardly see the chimney-piece of her 
ward when distant from it the length of the room ; also amenorrhea of 
ten months' duration, and great general nervousness. 

"This patient, immediately after her admission, had beien blistered 
over the eyelid on the frontal muscle, and had an issue put into the top 
of the head, and was subsequently mercurialized, but all without effect. 
She remained in the same unfortunate state when I saw her on the 17th 
of June, or one month after the application of blister and issue. 

"I applied magnetic electricity for the relief of the ptosis, for the first 
time, on the 17th June. She had experienced much confusion (as she 
expressed it) in the head, and had tremulous motion of the left eyelid 
previous to the electricity, which symptoms were diminished by the elec- 
tricity, and the eye felt stronger. 

"I continued the application of magnetic electricity on the 18th and 20th, 
by which time the ptosis was nearly cured, and the pupil of the left eye 
was less dilated, whilst its vision was improved. 

" On the 20th, as well as for a short time on the 18th, I also applied 
electricity to the region of the uterus, and on that evening she men- 
struated. This action continued on the 21st and 22d, and the fluid was 
natural both as to colour and quantity. 

" 22d and 23d — Found her a little feverish; therefore did not apply 
electricity. 

" 28th and 29th — Applied electricity this day for relief of the amauro- 
sis, she being in all other respects quite cured. After each operation she 
felt her head more composed, and sight of the left eye was by this time 
nearly perfect. After being electrified on the 29th inst., vision returned 
to the eye, which had been four months blind. 

" 30th— Applied electricity this day, and found after its application the 
cure of the amaurosis of leff eye was complete, and at several yards dis- 
tance she could distinguish the form and colour of small objects with the 
right eye. Doubtless that eye also would have been perfect in its vision 
after a few days longer, but she found it necessary to leave the hospital 
on the following morning, and came in the course of the day to my house, 
to thank me for (as she called it) her ' wonderful cure.' 

"This was, certainly, a most successful case, and the triumph of elec- 
trical power — ptosis, amaurosis, and amenorrhoea having all yielded in the 
short space of fourteen days, after having for thirty days previously baffled 
the highest medical skill. 



ELECTRO-MAGNETISM. 365 

"Theodosia Cunningham, late of Chatham-street, admitted 15th June, 
1842 — discharged cured ; temperament, hysterical and lymphatic. Dis- 
ease — total paralysis of right lower extremity, from hip downwards; limb 
so insensible that she might be pinched, cut, or a breast-pin inserted half 
an inch deep into any part of it without her being conscious of it. The 
foot was also distorted : the toes and fore-part of the foot pointing inwards, 
and the external metatarsal portion faced much towards the ground. Also 
catamenia had been suppressed for thirteen months ; but owing to some 
mistake, this fact was not communicated to me until the use of electricity 
to the sacrum and to the glutei muscles, in process of cure of the paraly- 
sis, caused their return. 

"In this case I applied the secondary electric current to the parts af- 
fected, during five weeks, in which time about twenty-five applications of 
electricity were made. The success was gradual, but complete. She was 
discharged on the. 2d of July, in full power of her limbs, having danced, I 
understand, in the ward previous to leaving it. 

"The catamenia were restored by an electrical operation on the 2d of 
July, in the manner above stated; and it is worthy of remark, that this 
discharge did not return until the very day when it was wont to manifest 
itself thirteen months before, although I had more than once before electri- 
fied these same parts. This teaches the importance of taking nature to 
our aid, by seizing on the time of her probable co-operation in the cure of 
disease. Not having been informed of the suppression of the catamenia, I 
did not know that it was secretion and discharge she alluded to when she 
requested me to cease the application of electricity for that day, which was 
Saturday, and it was only on my visit on Monday that 1 learned it, when 
too much time had elapsed for me to renew the operation. The discharge 
was very small in quantity; and it was intended that she should have re- 
mained in hospital until a few days previous to the time when the discharge 
might again be expected ; but as I did not come to hospital for some days, 
she thought that I had forgotten her case, and went home previous to this 
time. She had also pain in the right temple, and had lo^ use of her right 
eye, which she describes as having occurred about a year since, at the 
moment w T hen her arm (which had then recently become contracted) was 
extended by force. The pupil was not dilated; but there was a parti- 
cularly nervous look about both eyes — headache and loss of vision con- 
tinued. 

" This case was most remarkably successful, and excited much attention 
in the hospital. 

"Jane M'Kernan, aged 28 — sanguine bilious; admitted 16th June — 
discharged cured. Disease — suppression of the catamenia during ten 
months, being since her last confinement; nursed her infant five months, 
had inflammation of the pleura whilst nursing; got pains in chest and shoul- 
ders in February last, which still exist. 

"Electro-magnetism applied five times, from 21st to 29th June, with- 
out effect; objected to the further application of electricity, pleading fear 
of her being pregnant; it was therefore discontinued. 

"I am not at all surprised at want of success in this case, considering 
that it did not receive due perseverance, and that in all probability, the 
few times on which I did apply electricity, were not close to the period 
of the month when she usually menstruated; for she did not remember this: 
and thus I may have been acting in opposition to, instead of co-operating 
with nature. 



366 CLINICAL MEDICINE. 

" Abigail Duneley, aged 23 ; not married — temperament sanguineousand 
nervous ; admitted 20th July, 1842 ; left hospital when only twice electri- 
fied. Disease — irregular and deficient catamenial discharge ; also neural- 
gic pain in one side of head and temple. Did not know the time when 
catamenia usually occurred with her. On this account it might be neces- 
sary to apply electricity for many days before arriving at the time when, 
by co-operating with nature, we might hope our efforts to be successful ; 
yet she only remained to be electrified twice. 

"The neuralgic pain was relieved every time I applied the electricity, 
which was every second day ; and finding its effect on the day of its appli- 
cation, it was resolved to apply it daily; but in the interim she left hos- 
pital. In such a case, any useful result from the application could hardly 
be expected, as above shown. 

" Catherine Carroll, unmarried, late of St. Wolstans, Celbridge, ad- 
mitted 13th August, 1842 — discharged cured ; temperament hysterical 
and full ; health good previous to catamenial irregularity. About March, 
1840, being then two months without the catamenial discharge, large 
angry-looking boils (the largest were of the size and form of half of a 
small egg) appeared on the front of the tibia, none of them being in the 
lower extremities higher than the knee, around which joint they were 
numerous, they also appeared on the arms, and were finally absorbed 
with suppuration. 

" Got cold in May, 1840, and had pain in the left side, which extended 
generally over the pleura, and became dangerous in August of same year, 
when it was chiefly removed by medical treatment, but some pains re- 
mained about this part up to the time of her admission to this hospital. 

u About December, 1840, her feet, particularly the ancles, became 
swollen, this was succeeded by headache, or a sense of weight on the 
head, which was removed by blister to the nape of the neck. The cata- 
menia returned in May, 1840, and continued recurring at intervals of 
three weeks, until August, 1840, they were then suppressed from August 
to October, at which time they reappeared and continued regular until 
March, 1841 ; since which time, now nearly 18 months, they have en- 
tirely suppressed. 

" 16th to 19th August — Applied secondary electricity according to my 
usual practice. 

" 20th — Learned that she had menstruated on the previous evening 
after I had left her, but as the discharge was small, and as nature usually 
continues this action for two or three days, I did not deem it imprudent 
to apply electricity on this day also, being the second day of her men- 
struation, with a view of increasing the discharge, which is usually small 
after such long interruptions. 

"21st — Did not apply electricity further, and was glad to learn that 
yesterday's application was most seasonable, and the catamenial discharge 
ample both on that and the present day. 

" Patient feels much better, and pain in side is nearly gone — she is in 
fact cured. 

u Maria Smith, aged 20 ; feeble hysterical temperament. Eyes have a 
very peculiar cast, which some very hysterical patients possess — ad- 
mitted 12th August, cured 25th August. Disease — Catamenial irregu- 
larity and scantiness, causing fits of nervous terror and epilepsy. Had 
no catamenial discharge until her eighteenth year, when they appeared 



ELECTRO-MAGNETISM. 367 

regularly every third week, until she was nineteen years and three months 
old, but very scanty in amount. For nine months previous to this or 
from the period when she was eighteen years and six months old, being 
now eighteen months ago, she became affected with fits of nervous terror, 
when nineteen years and three months old, the catamenia became irregu- 
lar, occurring only every second month, and even then scarcely percep- 
tible ; since the catamenia became so irregular and scanty, the fits of ner- 
vous terror and epilepsy became more frequent and severe, generally 
occurring every day, and sometimes three or four times daily ; occasion- 
ally absent for several days, but always returning with a force stronger in 
proportion as they were longer absent. 

" In the milder form these fits consisted in an overpowering feeling of 
terror, in its stronger form a loss of consciousness and convulsive action ; 
in one of these last she fell into the fire and her cheek still bears evidence 
of the fact. 

" 23d August — Yesterday, the 22d, she had a trifling manifestation of 
the catamenia, being then six weeks since they last appeared, and as 
nature usually in healthy cases continues this action during three succes- 
sive days, I did not hesitate td apply the electro-magnetic current this day 
to the region of the uterus in my usual manner. 

" 24th — Found that yesterday's application, being in the proper time, 
had the desired effect, and the catamenia were renewed and larger in 
quantity than she had ever had them. This day also (being the third day 
of the menstruation), the catamenia still continue, and are equal in quan- 
tity to that which attends a healthy woman. 

"26th — Feels light and well, countenance natural, and has had no 
return of the fits since my first application of electricity to her, although 
previous to that time she had them each day since her admission to hos- 
pital. 

" 29th — Continues well and much improved in appearance. 

" Richard Brennan, labourer, aged 55 — temperament, sanguineous — 
admitted, 12th July, 1842 — discharged, cured, 27th August. Disease, 
lumbar rheumatism and sciatica, with neuralgia adjacent to the rectus 
femoris, vasti and other anterior and interior femoral muscles. Has been 
afflicted in this manner for more than three years ; attributes it to working 
when standing up to his hips in cold water. His case resisted all the 
usual treatment from the 12th ult., or nearly one month ; on the 8th, 9th, 
and 12th inst., I applied electricity (secondary current). 

u 12th August — Perfectly cured and continued well up to the day of 
his discharge ; namely, 27th inst. This was a most successful case. 

" Edward Murphy, labourer, admitted, 22d August ; discharged, 30th 
August, 1842 ; late of Liverpool and Manchester Railway. Disease, pain 
in the left side ; also in the os frontis, sternum, and clavicle ; also intense 
neuralgia, particularly at night, along the anterior and interior femoral 
muscles, as rectus, vasti, &c, &c, of right side, also pain in right knee. 
These pains usually became excruciating as soon as he became warm in 
bed, generally obliging him to leave his bed and attempt to walk, but at 
such times he could only do so by leaning on the hospital bedstead : there 
always remained in the morning a soreness of the part, yet it was not a 
cramp. 

u 23d — This day could not walk without a stick ; and having yesterday 
gone down stairs, could not return for nearly two hours, owing to the 



368 CLINICAL MEDICINE. 

pain. Had severe pain this day, previous to my applying magnetic 
electricity, which relieved it much. 

" 24th — Learned that the pain did not return as usual on his going 
into bed, and only appeared lightly near morning, and then did not 
deprive him of use of the limb. He is much pleased at success of the 
electricity. 

" 25lh — Found him free from pain, neither had he any on the pre- 
ceding night. Applied electricity as before. 

" 26th — Continues well. Electricity no longer necessary. This was a 
most successful case, and was quite similar to that of a man named Ryan, 
a Castle messenger, whom I treated equally successfully, in Saint Vin- 
cent's Hospital, in May last. This case had resisted the usual medical 
treatment. 

"John Kelly, aged 40 — temperament, bilious — admitted 28th July, 
1842. Disease, paralysis of lower extremities, with enlargement of plantar 
arch of left foot, particularly anterior and inferior to inner ankle — late 
servant to Mr. John Little, of Carrick-on-Shannon. About two years 
ago, appetite began to fail ; soon afterwards, felt as if stockings were 
gartered too tightly, which sensation lasted for nearly twelve months, 
during which time general lassitude was very distressing. This was suc- 
ceeded by a giddiness in the head, lasting about three-quarters of an hour 
each morning, and subsequently by pain in the instep and inner ankle of 
left foot, and an enlargement inferior and anterior to it. In December, 
1840, this enlargement became very considerable and hard, and the 
entire left lower limb became swollen, and was bandaged by a physician 
in Carrick-on-Shannon. About this time he lost the power of moving the 
lower extremities for three months ; he had also inability to pass urine, 
except by an instrument, for a month ; the arms were partially paralyzed 
at the same time, and he had moxas applied to the spine : he had six 
w T eeks previously been cauterized on each side of the dorsal spine, near 
its upper part, by a practitioner in Birr (King's County), without effect. 
The moxas were applied to the origin of sciatic nerve ; this took place in 
March, 1841, and by June of that year, he could walk on flat ground, but 
not safely up or down stairs ; and from June, 1841, to the present time, 
nearly fourteen months, continued in the same state, able to walk (on flat 
ground only) about one mile, with much stiffness of limbs, but unable to 
ascend or descend stairs safely, and therefore unable to follow his usual 
duty of servant. 

" No treatment, whatever, was given to this man except electrical. 
He has been electrified by me, since the 8th inst. (now the 29th), thirteen 
times, and is now nearly cured of paralysis. He moves with much more 
freedom, and not only walks up stairs, but is able to run up, taking two of 
the large stone stair-steps at each spring, touching, however, the banister 
with his hand as he springs. The enlargement of the plantar arch is a 
good deal diminished, and I expect a perfect cure will be made in another 
week." 

REMARKS ON MEDICAL AND ATMOSPHERIC ELECTRICITY. BY EDWARD S. 



" Dear Sir — In accordance with your wish I send herewith brief notes 
of all the cases in which I have applied magnetic and voltaic electricity 



ELECTRO-MAGNETISM. 369 

to patients in the Meath Hospital during the past three months, and also 
of two cases which I undertook in St. Vincent's Hospital. 

" I need hardly add that my private practice, under the guidance of 
yourself, Sir Philip Crampton, Sir Henry Marsh, Dr. Stokes, Surgeons 
Cusack, Smyly, Kirby, and other distinguished members of the profession 
in Ireland, would furnish additional instances in abundance of the very 
high importance of the various forms of electricity in the treatment of 
many otherwise incurable diseases. 

11 With reference to the apparatus I employ in such cases it varies much 
with the nature and extent of the disease. In most instances I use the 
secondary current developed either by a permanent magnet, or an electro- 
magnet, the magnetism of this latter being occasionally excited by a 
voltaic sustaining battery of the form described by me in Sturgeon's 
Annals of Electricity and Magnetism ;* and sometimes by a very potent 
thermo-electric arrangement, which I have lately devised, and which of 
itself promises to be productive of very important results in many cases 
where electricity of very low tension is desirable. All these instruments 
transmit their electric currents by directors furnished with moistened 
sponges instead of steel needles as formerly used with Cruikshank's form 
of battery ; a construction which I now rarely employ, and never transmit 
its current through any except platina needles. 

" The electricity derived from friction of glass, as the aura, sparks 
and shocks, I have not discarded, on the contrary I find the latter (sparks 
and shocks) to effect good service when other forms have failed, as in some 
varieties of catamenial suppression, in some rheumatic cases, and as 
resolvents of scirrhous and indolent tumour. The results in the Meath 
Hospital cases include — amaurosis ; ptosis ; complete paralysis of right 
lower extremity ; partial paralysis of both lower extremities ; complete 
paralysis of right arm ; lumbar rheumatism ; sciatica ; neuralgia, femoral 
and brachial ; edema ; catamenial suppression and irregularity ; spinal 
irritability. In fine, even in the short time I have had the honour to act 
under the guidance of the physicians of Dublin (only three months), I 
have verified nearly all the efficacy which has hitherto been attributed to 
this science, and great as I have shown its importance as a medical agent 
to be even in the narrow limits as yet assigned to it by the profession, 
I feel assured that it will soon be found applicable to a far more extensive 
range of diseases, and that higher triumphs await its progress, when it 
shall, by the profession, have been employed to stimulate the functional 
performance of more important organs found on a deliberate consideration 
of the theory which has led to its adoption as a medical agent, namely, 
its identity with the nervous influence ; and, perhaps, in illustration of 
this view you will permit me to take a hasty retrospective glance upon 
the causes which have gradually led to the introduction of electricity 
among medical agents. 

" Even before the present century, when that form of electricity was 
alone known which is developed by the friction of glass and silk, the 
rapidity with which volition was transmitted along the nerves to the mus- 
cles, had induced many persons to suppose that this was the agent em- 
ployed by nature to traverse the high road of the nerves as the messenger 
of its will, and it was then remarked by these observers, that these latter 
bodies w T ere by far better conductors of electricity than any other portion 

* « Sturgeon's Annals of Electricity and Magnetism, vol. iii., p. 84. 

25 



370 CLINICAL MEDICINE. 

of the human frame. It was subsequently observed that a strong spark or 
passage of electricity along any nerve called its dependent muscles into 
action ; these facts, combined with others, led many, even at that early 
period, to believe that the nervous influence and electricity were identi- 
cal ; still it was difficult to conceive how electricity of such high tension 
could exist in the human body, the fluids of which endow the entire with 
power of electrical conduction. But when the genius of Volta had at 
the commencement of the present century unfolded to the world a new 
form of electricity of tension so low that, with the exception of the nerves, 
which are excellent conductors, the animal solids would transmit it with 
difficulty, and when it was further seen that this new form of electricity, 
thus developed in a state of tension so low as to be quite consistent with 
the structure of the human body, exerted on the muscles, when transmitted 
to them by the nerves, a stronger action than frictional electricity had 
ever done; and further still, that animal matter alone, independent of 
metals, could constitute an arrangement capable of developing this elec- 
tricity, the electro-nervous theory received a great accession of probability. 
And when at a period a little later our own countrymen* had shown that 
this electricity of low tension was capable of decomposing saline fluids, 
and of eliminating their acid constituent at one extremity of the arrange- 
ment and their alkaline at the other, f it was soon seen that the secretion 
of our most important organs, as of the skin, stomach, liver, intestinal 
canal, &c, might be the result of the electrical condition of these organs 
impressed upon them at birth by Divine power; and hence, after the dis- 
covery of electro-magnetism by Oersted, the galvanometer was proposed 
as a means of discovering whether or not these organs, whose secretions 
are characterised by opposite chemical qualities, were not also in opposite 
states; and the result of this beautiful test was strongly confirmatory of 
this theory,^ for these organs all indicated opposite electric states whose 
secretions were of opposite chemical natures. Thus the skin, whose se- 
cretion is acid, indicated positive electricity when examined by the gal- 
vanometer, the intestinal canal indicated negative electricity, and its se- 
cretion has been proved to be alkaline, except in the stomach where it is 
acid, and there it indicates positive electricity. The stomach was found 
to be in one electric state, the liver in the other, the chemical nature of 
the secretions of each organ always according with that character which 
should result from the peculiar electric polarity in which the organ was 
found by the galvanometer to be. 

" Thus it was shown that in all human probability these hydro-electric 
currents detected by the galvanometer were the cause of all the secretions 
of our organs. At a still later period that accomplished electrician, M. 
Becquerel, showed that the acid and alkaline secretions of our various 
organs reacting on each other through the medium of the muscular and 
nervous tissues, must of necessity give rise to hydro-electric currents be- 
tween these organs, and hence the primary electric state of these organs 
having been impressed upon them at birth by Divine power, the first result 
was alkaline or acid secretion of each organ according to the electric, con- 
dition impressed upon each — these secretions reacting on each other de- 

* " Sir Humphrey Davy, Woliaston, Cruikshank, and others. 

f *• Transactions of Royal Society of London, 1814, p. 5S3 ; also of 1809. Philosophical 
Magazine (old series), vol. xxxii., p. 488. 

t " Becquerel Traite d'Electricite et du Magnetisme, Tome i., p. 322 to 327. 



ELECTRO-MAGNETISM. 371 

velop electric currents which again produce the secretions and maintain 
them during life, or so long as the electric condition of the organ con- 
tinues in its normal state. 

" In this stage of the electro-nervous theory I might easily adduce in 
its support the opinions of some of the most illustrious names of which 
philosophy and medicine can boast; but I must not trespass on the page 
of your valuable labours, and shall only remark that it followed from their 
opinions, as a matter of course, that at least in many cases abnormal se- 
cretion was the result of abnormal electric condition of the organs. 

"The valuable experiment of Dr. Wilson Philip, of Worcester* (made 
in presence of Mr. B. C. Brodie), on the identity of the nervous influence 
and electricity, added many converts to the electro-nervous theory. This 
experiment consisted in the proof that the functions of digestion and respi- 
ration of which a rabbit had been deprived by cutting the eighth pair of 
cerebral nerves, namely, the par-vagum or pneumogastric of the modern 
French school, could be restored by connecting the portions of these nerves 
which remained attached to the diaphragm with a voltaic battery instead 
of with the brain, from which the division and turning back of these nerves 
had separated it. This experiment showed the strong probability — that 
the secretion and functional action of the gastric juice as well as the action 
of the lungs, and the motions of the respiratory muscles are dependent for 
their existence on hydro-electric currents, and if it did not strictly prove 
the identity of the nervous influence and electricity, it gave great weight 
to that opinion, and proved that the latter could be substituted for the 
former without inconvenience to the animal economy, and lastly, it aided 
in directing the public mind to the important conclusion, that when dis- 
ease has impaired the action of these important functions, it probably does 
so by altering the normal state of the natural electric sources, and that the 
action of these on the system, which is so essential to our most important 
secretions, may be supplied by electricity, if this latter be rnade to resemble 
that of nature in quantity, direction, and intensity. 

" We are thus led by the experiment of Dr. Philip, and the amply proved 
existence of hydro-electric currents circulating between the organs of secre- 
tion (as proved by Le Donne, Marianini, Orioli, and Becquerel), to see 
that the processes of secretion and digestion are hydro-electric phenomena, 
and thence to appreciate the importance of judiciously administered elec- 
tricity of low tension in restoring a healthful condition to the secreting and 
digestive organs, and to witness the greatly increasing probability that in 
all cases of secretion, digestion, sensation, and motion, electricity is the 
great natural agent and is identical with the nervous influence. It is true 
that as yet I have not brought forward any argument to prove that electri- 
city attends, and is the cause of all human motion, a proof which appeared 
necessary to be given before we could be called upon to acknowledge its 
identity with the nervous influence. This proof, which could not be af- 
forded until the connection between the sciences of electricity and magne- 
tism was well understood, has recently been afforded to a great extent by 
Dr. Favio and Professor Zautedeschi, in Italy, f who have shown that in- 
dependently of the electro-chemical currents just alluded to as ruling the 
secretions, there exists (at least in all warm-blooded animals) another class 
of electric phenomena, of at least equal importance, presiding as they do 

* " Transactions of Royal Society of London, 1822, part 1, p. 2. 

f " Bulletin de l'Academie Koyale des Sciences et belles Lettres de Bruxelles, T. vii., partie 
2, p. 43. 



372 CLINICAL MEDICINE. 

over all voluntary motion. These phenomena consist in the passage of an 
electric current along the nerves of each limb to their corresponding mus- 
cles, they exist only during the motion of the limb, are detected by the 
galvanometer, and as they differ both as to source and direction from the 
hydro-electric currents which, under the guidance of life, cause the secre- 
tions, their discoverers have named them * electro vital,' or 'neuro elec- 
tric' currents. 

" The experiments of these gentlemen consisted in attaching a.metallic 
stilet to each end of the wire of an exquisitely delicate galvanometer, one 
of which stilets was kept (by its insulated handle) in contact with the nerve 
leading to any limb, whilst the other was sunk deeply into the body of the 
muscle, of which the action was to move the limb. The animal was then 
excited to move the member, when it became evident, that at the instant 
of every movement a current of electricity passed along the nerve and gal- 
vanometer in the direction of from nerve to muscle. This experiment was 
certainly very beautiful, and its results, if free from ambiguity, would be 
most valuable; yet, as so much of difficulty is opposed to obtaining accu- 
rate results under such circumstances, particularly as the stilets were of 
oxydizable metals (iron or silver) on which the animal fluids could exert 
chemical action, and, therefore, generate hydro-electric currents indepen- 
dent of any vital action. I think that we cannot rest with such confidence 
upon them, as on the apparently decisive experiments of M. Prevost, of 
Geneva, lately communicated by M. De La Rive, to the Royal Academy 
of Sciences of France.* M. Prevost's experiment consisted in showing, 
that when a sewing-needle had been inserted into the crural muscles of a 
frog, and parallel to the longitudinal direction of the muscular fibres, and, 
therefore, at right angles to the capillary termination of the nerves distri- 
buted to these muscles, it became sufficiently magnetic to attract light par- 
ticles of the filings of iron whenever contraction was excited in the muscles 
by stimulating the cerebro-spinal origin of its motor nerve. This was in- 
deed the most complete proof imaginable, that a vital current of electri- 
city is actually sent along the nerves to the muscles from the cerebro-spinal 
origin (of the former) whenever motion is produced ; for the magnetization 
of the needle which took place at every motion of the limb could be pro- 
duced by no other means than the passage of an electric current along the 
nerve, and is precisely that which w T e should expect from the well-known 
electro-magnetic law, first made known by Professor Oersted, namely, that 
magnetism is always developed in any conducting substance placed at right 
angles to an electric current. 

" Thus is made manifest to the sense of vision, the truth of that beau- 
tiful theory, which assigns to the motor nerves the office of conductors to 
that electricity which the brain sends to the muscles as the messengers of its 
will for the production of all corporeal motion. Hence we have reason 
to believe, that the vital electric current, which M. Prevost has shown to 
accompany motion in the living animal, is really the cause of all human 
motion, and are led to look with confidence to the use of artificial elec- 
tricity as a means of restoring the powers of voluntary motions to such 
parts of the human body as have become partially and recently deprived 
of it, in consequence of paralysis of the motor nerves, arising either from 
slight structural alteration, or deficient power of setting into motion the 
natural electric fluid at their origin. 

* " Philosophical Magazine, vol. xii., p. 294 (new series). 



ELECTRO-MAGNETISM. 373 

" The general results of the experiments alluded to, seem to indicate a 
division of the nervous system into two classes, of which one presides 
over the muscles of voluntary motion ; the other over those of involuntary 
motion and organs of secretion. The influence of the first is produced at 
pleasure from its cerebro-spinal origin — that of the second owes its power 
to hydro-electric action ; and if so, it is w T ise)y, indeed, ordained by the 
great Creator, for if the secretions had depended on our will, and on the 
action of the mind, our first night of repose would be our last of existence. 
It is true that the secreting organs have cerebral and spinal nerves, and 
this may account for the influence of the mind on the digestive organs ; 
but to a great extent the distinction appears well founded. 

" I must apologise for this trespass upon a province not properly my 
own, and close this hasty sketch of the reasons which induced many to 
adopt the opinion, that the nervous influence and electricity are identical, 
by remarking, that the practical result which has followed its adoption on 
the Continent, in the hands of Magendie,* Marianini,f Palaprat, and 
Orioli, and in this country by yourself, Sir Philip Crampton, Sir Henry 
Marsh, Dr. Stokes, Surgeons Cusack, Smyly, and others (whose humble 
instrument I had the good fortune to be), is such as to confirm this theory 
in a very remarkable degree. But as I have already said, I feel that we 
are as yet but in the infancy of the application of this science, and that 
the time will soon arrive, when the suggestion first thrown out by Pro- 
fessor Orioli, J of remedying abnormal secretion, by altering the electric 
state of the secreting organ, will soon be carried into full effect ; neither 
will the task of reaching these organs be found so difficult as might at first 
be supposed, when it shall be understood that it is not necessary that the 
part whose electric state we desire to alter, should form a part of the 
electric circuit, but that on the contrary, the electric current is not limited 
to the space which lies between the poles of the apparatus, but passes 
beyond it, following the course of the nerve so as to affect parts below, 
and quite exterior to the space supposed to be the passage of the electric 
current. Thus if one director be placed on the origin of the sciatic nerve, 
and the other on the popliteal space, the current will not be confined to 
the portion of the nerve which lies between the directors, as one might 
expect, but will act forcibly much below it, even to the plantar extremi- 
ties ; and I am often obliged to adopt such a course, where the nerve of 
the part to be acted upon is deep seated in that part, but is more super- 
ficial in some point nearer to its origin. 

" With reference to the facility with which electricity removes various 
forms of disease, I believe I may remark that I have found it to act more 
quickly in neuralgia than in any other, as it occasionally cures some 
varieties of this disease in two or three applications, but in others, often 
requires a feeble electrical current for many successive days. 

" Next in order of facility come rheumatism and sciatic cases, then 
cases of deafness. After these come some varieties of catamenial sup- 
pression. It acts also readily on certain curable forms of amaurosis, then 
in partial paralysis, and with greater difficulty in hemiplegia than in 
almost any other form ; as this disease requires many weeks of daily, 
and, perhaps, constant application, by means of the sustaining battery. 

* " Comptes rendus premier Semistre. No. 24, Annee, 1840. 

f u Bibliotheque Universelle, T. lii., p. 351. 

+ " Becquerel Traite d'Electricite et du Magnetisme, T. i., p. 325. 



374 CLINICAL MEDICINE. 

And here I may mention, as an instance of the value of electric treatment, 
that in this disease I have always found those muscles soonest restored 
to voluntary power, to which electricity had been the more constantly 
applied. 

" There is no doubt, that the application of electricity to the head and 
its neighbourhood (after the symptoms of cerebral inflammation have 
subsided), requires great caution, otherwise, the most dangerous conse- 
quences might follow ; needles should never be employed as directors to 
this part. Even when simple voltaic electricity is employed, the current 
from two or three pair of plates only an inch and a half square, would be 
attended with extreme danger if needles be employed ; yet with care and 
attention to circumstances as they arise, the electro-magnetic current may 
safely be applied, through the medium of sponges, from the first cervical 
vertebra to the foot, varying the treatment as the disease demands. 

" As a fellow member of the Royal Irish Academy, you have been 
aware of the laborious series of meteorological observations and researches 
which I have made, at the recommendation of the council of thatlearned 
body,* with a view to discover the connection which exists between 
atmospheric electricity and other natural agents ; such as temperature, 
barometric pressure, hygrometic condition of the air, both as to free or 
uncombined moisture, and as to the absolute quantity of aqueous vapour 
existing therein, in what state soever of dryness it might be ; so as to 
deduce from the action of one or all of these agents the natural law which 
causes the diurnal changes of atmospheric electricity, and to give a correct 
statement of the condition of all these atmospheric agents at each hour of 
the day and night. You have requested me to say in this place a few 
words upon the subject, in order that you may compare the progress of the 
diurnal changes of atmospheric agents with the periods which you have 
observed to affect the daily stages of acute diseases. 

" I have, therefore, to observe, that atmospheric electricity has one 
gradual ascent from 3, a.m., which is its minimum, to 3, p.m., which is 
its maximum hour ; excepting, how T ever, from this statement the fact, 
that there occurs a slight sudden ascent from 8 until 10, a.m., and a con- 
siderable ascent from 5 until 7, p.m., w 7 hen the intensity even exceeds 
that of 3, p.m. This intensity, however, speedily subsides, and we may 
regard 3, p.m., as its diurnal maximum. 

" The quantity of aqueous vapour in the atmosphere as indicated by 
the dew point, after all necessary corrections are made, has also its mini- 
mum at 3, a.m., and its maximum at 3, p.m. 

" The thermometric curve exhibits its maxima and minima at the same 
hours, namely, minimum at 3, a.m., maximum at 3, p.m. 

" The barometer curve exhibits two maxima and two minima in each 
twenty-four hours, namely, a diurnal maximum at 10, a.m., and minimum 
at 4, p.m., and its nocturnal oscillations occur at the same hours. These 
variations in the height of the mercurial column amount, according to my 
observations, to -020 of an inch, which is equivalent to an alteration of 
pressure, amounting to 4-2 ounces on each superficial inch of the human 
body. This considerable reduction in the amount of the external atmo- 
spheric pressure, whilst the internal pressure of the animal fluids remains 
unchanged, would seem to lead to the conclusion, that the hour of 4, p.m., 
must be distressing to invalids, but still more so that of 4, a.m., when the 

* " Proceedings of Royal Irish Academy, 1839 and 1840, part 4. 



ELECTRO-MAGNETISM. 375 

reduction of external pressure also exists, and the stimulating sources of 
electricity and external heat are both at their minima, and the aqueous 
vapour of the atmosphere is in its most uncombined condition, depositing 
itself insensibly on the surface of the body, and thus tending to lower 
its temperature at a moment when the vital forces are least able to resist 
this action. 

" The foregoing meteorological results are deserving of every reliance, 
having been obtained by a most laborious series of observations made by 
me during twelve months, at which time the electricity of the atmosphere 
was observed at intervals of fifteen minutes, during, at least, fifteen suc- 
cessive days in each month, and from five to ten nights, the temperature 
of the air was observed as frequently ; the height of the barometer was 
noted each half hour during the same time, and the dew point was taken 
hourly with a Daniel's hygrometer during the same period as the other 
instrument. 

11 The electrometer employed was one of my own invention, and not a 
mere hygroscope, as all the former gold leaf electrometers were, but one ca- 
pable, of measuring, with accuracy, the slightest change of intensity, as well 
as of giving indications of electricity so feeble as to escape observation 
with ordinary instruments.* The barometer, thermometer, and hygrome- 
ter, were also accurate instruments, constructed with every care for the 
occasion. The result has been satisfactory in the same proportion, point- 
ing out, as I think it clearly does, the law which in nature regulates the 
diurnal variations of atmospheric electricity, and its intimate connection 
and dependence upon two out of the three great natural agents, with 
which I had proposed to myself to investigate its connection. This law 
will clearly appear when we remember the experiment of Volta, in which 
it was shown that whenever water, not absolutely pure, is evaporated from 
an insulated vessel composed of materials similar to those which compose 
the crust of our earth, the vessel from which the evaporation takes place 
is left in the negative electric state, in consequence of a portion of its 
natural quantity of electricity being taken up in the latent state by the 
vapour, as it forms, whilst this same vapour manifests all this extra sup- 
ply of electricity when it becomes condensed on the surface of a cold and 
insulated body, which latter then appears strongly positive, because the 
aqueous vapour, in the act of condensation, has set free that redundant 
quantity of electricity which it had previously taken up in a latent form 
from the insulated vessel, out of which it had been evaporated, and which 
was only necessary to its aeriform existence. 

" Thus we see that the electricity of the earth (when uninfluenced by 
the inductive action of passing positive clouds) is negative,! relative to 
that of the surrounding atmosphere, in proportion to the quantity of aque- 
ous vapour which has been evaporated from its surface. This ought to 
make the indications of their relative difference, as exhibited by an elec- 
trometer, greater in proportion to the sun's altitude, or rather in propor- 
tion to the temperature of the respective hours ; and this I have found to 
be the case, with the exception of the slight sudden increase of tension, 

* " See a description of this instrument in the proceedings of the Royal Irish Academy, 1839 
and 1840, part 4. An instrument of this description has since been taken out with the Niger 
expedition; it was furnished by Watkins Hill (to Dr. M' William, surgeon to the Albert) 
according to my drawings. — E. S. C. 

f " This fact of the earth being negative, relative to the air, has been acknowledged to be 
true by every observer. 



376 CLINICAL MEDICINE. 

4 

which occurs from 8 until 10 in the morning, and of the sudden but con- 
siderable increase which occurs from 5 until 7 in the evening (always 
speaking of the mean curve of each day, as derived from the annual ave- 
rage). This sudden increase of tension at those hours arises from the 
condensation of the aqueous vapour, in the form of dew, # which, as 
before shown, must liberate its previously latent electricity. 

" The foregoing opinion relative to the time and cause of the diurnal 
variations of atmospheric electricity is valuable because that is not the 
expression of any pre-conceived ideas which might have influenced my 
reading of the results of my researches, but on the contrary, was quite 
unexpected as to the hours themselves; and the cause only then occurred 
to me when I held in my hand the various annual curve charts of the 
hygrometric and thermometric condition of the atmosphere at each hour, 
and observed their obvious connection and dependence. Indeed, I had 
been insensibly led by the high character attributed to the observations 
and researches of Professor Schiibler, of Stutgard, to anticipate very dif- 
ferent results, as that philosopher made the minimum hour to occur at 2, 
p.m., and thus expresses himself as to the want of influence of temper- 
ature on the diurnal variations of electricity : — f 

" 'It is necessary to remark that these diurnal periods correspond very 
little with the advance of diurnal temperature in the same place, and that 
in this regard there cannot be a question of the smallest parallelism. If 
the first minimum of atmospheric electricity manifests itself a little before 
the rising of the sun, when the temperature of the day is lowest, the 
second presents itself, on the contrary, from 2 to 4 or 5, p.m. ; that is to 
say, in the warmest part of the day. But if there is but little analogy in 
this regard, there is so much the more under that of the humidity and 
visible vapours in the atmosphere. We observe the maximum of the 
daily period after the rising and setting of the sun, at hours when the 
air presents the greatest quantity of vapours, as well to the hygrometer as 
to our view.' 

"But as that gentleman only made two observations daily, we need 
not wonder that the disturbing inductive influence of passing clouds 
marked the true hours of variation, and consequently its true causes. My 
explanation of the cause of this diurnal variation differs also from that 
given by De Saussure and his followers ; namely, the conducting state of 
the aqueous vapour. The electric tension being supposed to be strong at 
the maximum hour, because neither too great dryness or too much moisture 
then prevailed, the former of which would prevent the aerial electricity re- 
turning to the earth through our instruments, and the latter would neutralize 
their electric states by its too great conducting power, whilst my explana- 
tion, as already shown, rests not on the conducting power of the vapour, 
as influenced by its state of combination, but on the absolute quantity of 
aqueous vapour, as indicated by the dew point, when all necessary cor- 
rections for temperature have been made, the relative electric condition of 
the earth and its atmosphere being always most different when the greatest 
quantity of aqueous vapour is indicated by the dew point. But this result 
is not to be discovered by contemplating the progress of electric intensity 

* " See Pictet Essai Sur ]e fue, 8. 35; also Bibliotheque Universelle Sciences et Arts, 93. 
— On morning as well as evening dew. 

■j- u Reserches Sur L'Electricite Amospherique par M. Schiibler (Bibliotheque Universelle 
Sciences et Arts). 



ELECTRO-MAGNETISM. 377 

and advance of the dew point upon individual days, but only first by the 
monthly curves, and still more clearly by the annual curve, the natural 
law becoming more evident in proportion as the observations are more 
numerous, for when very few observations are made, the chances of their 
being falsified by the disturbing influence of passing clouds, is very great 
indeed. 

" As it is interesting to trace (so far as our limited knowledge can) how 
few the primitive agents are, which the Almighty uses for the production 
of the numerous and important phenomena dependent on creation, em- 
ploying these few in such endlessly varied forms that we no longer recog- 
nize their existence ; whilst some of the numerous secondary agents, aris- 
ing from that mutual connection and dependence, appear to work out 
natural phenomena, with so much apparent energy and singleness, that 
we frequently believe them the original agents under Providence, thus 
erroneously multiplying causes, by considering effects as such, whilst in 
reality the infinite wisdom of the great Creator, foreseeing all possible de- 
pendencies and changes, used but a few principles to accomplish all his 
marvellous productions. As he has formed all substances upon this our 
habitable earth out of such few materials as that even with our present 
imperfect chemical skill, we have been able to reduce them to 52 elements, 
and it is likely, as our progress in chemical analysis advances, we shall 
find this number much reduced, so, in this same point of view, it is in- 
teresting to notice that electricity of the atmosphere, that invisible and 
extraordinary agent which is at once the terror and the ornament of the 
sky, as developed in aurora? or in lightning — which is, with much proba- 
bility, believed to be the safety of the mariner on the boundless ocean,* 
which is essential to the purity of our atmosphere, and formed the crys- 
taline beauty and treasure of the mineral kingdomf thus bowing chemical 
effects to its power, is the result of the action of one body on water, and 
that body the same which maintains the planets in their orbits — the sun — 
the centre of the planetary system. When I say so many effects are thus 
seen to result from the action of one body (the sun), and when we know 
that its light and heat are necessary to the existence of every organised 
being in the planetary system, what an idea becomes impressed upon us 
of the wisdom of the great Disposer of all things, and well may we ex- 
claim in the language of the poet, 

" ' His wisdom guides the rushing wind, 
And tips the bolt with flame; 
His goodness breathes in every breeze, 
And warms in every beam.' 

" Neither is this universality of action peculiar to the great luminary we 
have been speaking of, but is common to all the great agents in nature 
(and even those of a secondary character). Thus we see the multiplied 
offices of the atmosphere, the moon, &c. &c; indeed this is so obvious, 
that I have great reason to apologise for the trespass upon your valuable 
time by the remarks which I have made upon it ; but as the sun's action 
is not generally known to be the cause of the diurnal changes of at- 

* "Thermo-electric currents at the equator being believed to cause polar magnetism. 

f "See the results of Becquerel, Cross, Fox, and others, in producing mineral crystals 
(by means of electric currents of low tension), which chemistry had in vain previously 
attempted. 



378 CLINICAL MEDICINE. 

mospherical electricity, I thought this digression not altogether out of 
place. 

u Believe me to be, Sir, 

"With unfeigned admiration and respect, 
"Your most obedient servant, 

« E. S. CLARKE. 

"18, York Street r 

POSTSCRIPT TO MR. CLARKE'S CASES. 

John Kelly'* s Case [conclusion of) y see page 427. 

" From the 29th August to the 9th September I applied electro-magne- 
tism of very high tension to this man five times ; on the 9th September 
he left hospital, but came to my house and was electrified daily until the 
20th, by which time the enlargement, anterior and inferior to the malleolus 
internus, had almost entirely disappeared ; and he was able to walk with- 
out difficulty several miles each day over even a hilly and rough road ; 
and on the day last named, returned to the country to resume his duties 
with his former master, who, aware of his progress towards recovery, had 
kindly reserved his situation for him. Previous to his leaving Dublin he 
presented himself to Surgeon Porter, at whose instance I had attended 
him; and who has since expressed to me his great satisfaction at the cure 
which was thus accomplished. I have since heard of this man through — 
Thompson, Esq. (student under Surgeon Maurice Collis), who took a great 
interest in him ; he states that he finds no difficulty in walking or discharg- 
ing any of his duties as a servant. This man was electrified about thirty 
times. 

" Charles Crean, aged about 70, formerly butler and house-steward to 
the late Lord Bishop of Kilmore. Disease — paralysis of bladder. This 
man was quite unable to void urine, and it was accordingly drawn off 
with the catheter three times each day, by the resident surgeon. His 
mind has been astray during nearly the entire of the past twelve months. 
He was affected with this complaint (paralysis of bladder) for some weeks 
previous to his entering this hospital; it manifested itself suddenly during 
a paroxysm of mental aberration. 

"8th October — As directed by Dr. Stokes, I this day applied second- 
ary current from sacrum to pubis and along the course of the abdominal 
muscles. 

" 9th — This morning he voided naturally a few drops of urine. I ap- 
plied electricity in same manner as on yesterday. 

" 10th — Applied electricity as on preceding days; tone of the bladder 
seems about to return as he voided a little urine twice this morning either 
whilst being electrified or immediately afterwards; in all about a wine- 
glassful ; it was propelled at first nearly two inches from point of penis. 

" 11th — Applied electricity as before ; mind appears rather more wan- 
dering, projectile force of bladder rather less; but made, at four or five 
attempts, about the same quantity as yesterday. 

" 12th — Applied electricity this day from perinseum to about half an inch 
above upper part of the pubis ; also occasionally in the former method. 

" 13th — Applied electricity in the same manner as yesterday; he voided 
more water, but mind is wandering, and he seems desponding and inac- 
tive as well as impressed with a great dread of some unknown danger. 
Catheter is still daily applied at his most anxious request, although becom- 



ELECTRO-MAGNETISM. 379 

ing each day less necessary. This night he attempted to commit suicide 
(by cutting his throat), but fortunately did not make any dangerous inci- 
sion. As the bladder is evidently recovering its tone fast, and as he is so 
excitable, I have discontinued the electricity; it had, however, accom- 
plished its purpose as he daily voided urine spontaneously, and by the 16th 
inst. the catheter became unnecessary. I regard this as a most important 
case, particularly as no remedy was resorted to except electricity. 

11 Luke Byrne, aged 33. Disease — paralysis of both lower extremities; 
he complains also of a sensation of a ligature around the abdomen, and 
refers his paralysis to this cause, which he also believes to have been much 
increased by excessive internal and external use of spirits of turpentine. 
Having applied electricity to this man for seven successive days without 
effect, I desisted from its further use, particularly as Dr. Stokes thinks it 
likely that he is affected with disease of the spinal canal. I feel, however, 
that other electric instruments ought to have been tried in this case, which 
could not be done for want of a room, especially devoted to electrical ope- 
rations, where instruments not very portable could be left and kept in 
order. Rubbing with mercurial ointment and other treatment has been 
resorted to, from the 14th inst. to this time, the 26th, the constitutional 
action of mercury has appeared, but the paralysis remains unaltered. 

11 Theodosia Cunningham. Disease — amenorrhea ; recommended by Dr. 
Graves. This is the same individual whom electricity so effectually cured 
in hospital of paralysis of right lower extremity ; by reference to her case 
it will be seen that she suffered under suppression of the cataraenial dis- 
charge for thirteen months preceding July last, but which fact I was not 
aware of until electricity produced its return on the 2d of July, whilst I 
was in the act of applying electricity to the glutcei and other muscles in 
the neighbourhood of the uterus; and it was remarkable that nature ad- 
hered in that case to the period of her usual action with this girl, namely, 
the 2d of the month, nor was electricity able to produce it until that time 
arrived, although applied to the same parts on many preceding days. 
The catamenial discharge was, however, very trifling, owing chiefly to the 
application not having been made to the appropriate parts in consequence 
of the reason already explained, and being then under the impression that 
it would be improper to renew the application on the following day lest 
it should alter the regularity of the natural periods, an instruction which I 
received from a physician accoucheur of considerable standing, the oppor- 
tunity was lost for that month ; and although the paralysis was cured the 
violent headaches continued. No attempt was made by nature to remove 
the catamenial discharge. On the succeeding period, under those cir- 
cumstances, experiencing constant and violent headaches and other hys- 
terical sensations, and especially dreading a renewed attack of paralysis, 
she again applied to Dr. Graves, who believed all her illness to result 
from catamenial suppression, which might be said to have then lasted fif- 
teen months, and for the temporary relief of the consequent symptoms 
blood had been in vain taken jn the course of the preceding year, once 
from the nape of the neck by cupping, and twice from the arm by the 
lancet, and consequently requested me to apply electricity with a view to 
produce a return of the menses, accordingly I began at the period when 
she might, for their return being the 2d of September, I began a few days 
previously to apply a feeble secondary current, as usual in these cases, 
first on the 27th, then 29th and 3lst, and on the 1st and 2d of September, 
more strongly, but without success. 



380 CLINICAL MEDICINE. 

" 3d Sept. — In consequence of success not having attended the appli- 
cation of electro-magnetism even on the preceding day, I insulated her 
and connected her with the negative jar of a Nairnes electric machine of 
large size, and passed about ten shocks of moderate intensity in each of 
the directions I am accustomed to send the electro-magnetic current. 
Success followed before I had administered many shocks, menstruation 
began, but was small in quantity, and not sufficient to prevent .me from 
continuing the application of the shocks. Having adopted the idea that 
it would be rational practice to apply the electric current on the second 
day of the menstruation, whenever the secretion should prove too scanty, 
I renewed the application of shocks on the following day, the 4th Sep- 
tember; on that day as on the preceding, the catamenial secretion made 
its appearance, not continually, but only every third or fourth hour, and 
this in very small quantities, whilst headache, sickness of stomach, with 
hysterical symptoms, were very distressing, under these circumstances I 
consulted Dr. Graves, and he advised a repetition of the preceding day's 
application, on Monday, the 5th September, being then the third day 
of her menstruation, but the fourth day removed from that of her usual 
period. 

" On coming this day to be electrified, she was exceedingly hysterical, 
whilst head and stomach were even more unwell than usual, on preceding 
days. Nevertheless, I passed two shocks, which produced a slight return 
of the menses. I also gave some sparks to her arm, which she believed 
was about to be visited with nervous paralysis. She left the house very 
sick, but had scarcely done so, when the catamenial secretion came on in 
greatly increased quantity. On reaching home, she discharged from her 
stomach a watery and greenish-looking liquor (as she described it), whilst 
the discharge became far more considerable than it had ever been, and 
such, both as to colour and quantity, as healthy women generally secrete. 
This discharge continued during the entire of Monday and Tuesday, as 
well as to a less extent until Wednesday morning, the 7th instant, when 
she felt quite well ; had lost her morning headaches ; regained colour in 
her cheeks ; and lost the peculiar hysterical appearance of the eyes, which 
up to that time had characterized her. And, I think, that instead of being 
a victim to headaches and hysterical sensations, which threatened her 
with nervous paralysis, such as she had twice before been afflicted with, 
she may now expect to enjoy excellent health, being naturally of a robust 
constitution. 

" I regard this case as peculiarly important, as it establishes two facts 
fully : first — that although our efforts in the cure of this disease ought to 
be undertaken as near to the natural period in each individual as possible, 
that still it is a good practice to persevere for three or four days after that 
period, if the secretion be either absent or deficient in quantity. This 
woman always experiences pain in the back during the secretion of the 
menses. Secondly — that no catamenial case can be said to have over- 
come the power of electricity, until frictional, as well as magnetic, elec- 
tricity, shall have been both tried ; and hence, that in all probability, the 
only two unsuccessful cases of this disease which I have had in the hos- 
pital, and which are recorded in my notes, would not have been so, if a 
room expressly devoted to electricity had existed in the hospital — an 
opinion which my experience in many other diseases, such as rheumatism 
and paralysis, decidedly induces me to extend to them. 



ELECTRO-MAGNETISM. 381 



" saint Vincent's hospital. 



" Anne Thrimback, formerly 110, Marlborough-street, admitted 25th 
April — discharged 20th June. Disease — paralysis of left arm, which was 
much wasted. 

" 1st June — applied secondary electric current, from origin of fourth 
curvical nerve to palm of hand, and occasionally to ulnar nerve ; also, 
through the trapezius, deltoid, biceps, flexor cubiti, and triceps extensor 
muscles. I repeated this application every second day (not having leisure 
for daily operations), until the 13th, from which time the application was 
made daily until the 20th, on which day she was discharged, being then 
quite cured. 

11 Thomas Ryan (messenger in Dublin Castle), admitted 6th June — 
discharged 17th June. Disease — neuralgia of the sciatic nerve as far as 
the popliteal space, and of the anterior crural nerve ; pain intolerable at 
night in rectus femoris, vasti and other adjacent muscles. Had large 
blister over the loins without effect ; also used hydriodate of potass and 
camphorated mixture. 

" 10th June — applied secondary electric current from origin of sciatic 
to popliteal space ; also, from sciatic origin, and occasionally from the 
obdurator nerve and sciatic notch along the rectus femoris, vasti, and 
other anterior femoral muscles. On visiting him on the 12th, he stated 
that he had not been afflicted with any return of the pain, and, therefore, 
did not deem it then necessary to renew the application. But having 
experienced on that night a slight return of the pain, I applied the electric 
current as before, after which the pain returned no more, and he was dis- 
charged cured on the 17th instant. 

" Thus far I have given notes of the additional hospital cases, of which 
I esteem Crean's case, in which I was fortunate enough to cure paralysis 
of the bladder, as of very high importance, directly pointing as it does to 
the effective action of electricity upon organs essential to our existence, 
and which another case at present under my care confirms, as far as the 
bowels are concerned. I cannot, however, close these notes without 
calling attention to one case selected from your private practice, as indi- 
cative of the highly restorative action of electricity in hemiplegia. 

" The case I allude to is that of Master B. . This young gentle- 
man, age about 17, retired to bed in good health, on the 19th July last. 
During that night he was visited with apoplexy, and in the morning it 
was discovered that he was perfectly paralyzed throughout the entire of 
the left side. The voice was unaffected ; but whenever he attempted to 
put his tongue out, instead of going straight forward, it was protruded at 
the side of the mouth. On the paralyzed side the limbs were flaccid and 
motionless, and sensibility w T as entirely extinct ; the bladder and rectum 
were also involved in the paralysis. 

" Previous, however, to your having directed the application of mag- 
netic electricity, you had by other treatment restored to a considerable 
extent the power of sensation ; but all power of motion was altogether 
absent. The tongue was still paralyzed ; the sphincters of the anus and 
rectum were also in the same state, the urine and fecal matter being still 
voided without his control. The sound side was unable to support the 
other w T hich was paralyzed. The limbs were greatly wasted, particularly 
those on the paralyzed side, whilst the skin on same was withered and 



382 CLINICAL MEDICINE. 

inanimate-looking. He was in this state on the 12th of August, when 
you directed the application of magnetic electricity to the lower extremity, 
at the paralyzed side, and along the spine daily, having determined on 
the trial of electricity unaided by any other remedies. During the first few 
days of application no remarkable change took place ; strength was grad- 
ually being restored ; the skin of the affected side began to lose its 
withered and inanimate appearance ; whilst the lower paralyzed and 
wasted extremity appeared to be increasing in fulness. This stage was 
followed by frequent involuntary movements of the lower limbs. And it 
is worthy of remark, that the muscles to which electricity was most fre- 
quently applied, were those which first manifested involuntary motions, 
and subsequently soonest became obedient to the will. After involuntary 
movements of the lower paralyzed limb, the intestinal paralysis ceased, 
and on the 3lst of August, or nineteen days after the first application of 
electricity, the flexor muscles of the paralyzed leg began to resume their 
power. After a lapse of nine days more, in all twenty-eight days, he 
could each morning execute one voluntary extension of the leg, but only 
one, and that only when just after waking, and in full power after a night 
of repose. Fear of cerebral inflammation being less urgent, I have for 
many days past applied electricity to the upper portion of the spine and 
arm, and by this time many involuntary movements took place in the 
arm, particularly at night, and on the 13th of September he could move 
the fore-arm and humerus upwards and inwards ; but the biceps flexor 
cubiti was then very weak in its contractile action, and the pronator radii 
teres being more powerful than the supinator, caused the fore-arm and 
hand to fall inwards and forwards when he attempted to raise his arms. 
The great toe, also (but none of the others), began to evince a power of 
withdrawing itself from a pinch of my finger, or from a strong electric spark. 

" On the 23d Sept. power began to return to the extensors of the leg, and 
on the same day he left his bed and sat up in a chair for an hour or more. 

a Application of electricity was discontinued on the 31st of September 
(seven weeks from its first application), owing to the patient appearing 
feverish. I saw him a few days ago (on the 20th of October) : his strength 
has so much increased, that he can walk well by the aid of a stick, and 
his general health is good. There remained, however, an awkwardness 
in moving the left side, and certain muscles were comparatively inactive, 
which gave rather a paralytic appearance to his movements ; but as it is, 
I believe, intended to renew the application of electricity, and as his case 
in all its stages yielded gradually to this agent, I think that in all proba- 
bility even these defects will be removed. 

"In the progress, I have resorted to nearly all the known sources of 
electric power, as well as to many new forms of apparatus, and have for 
weeks together kept electric currents circulating through the paralyzed 
limbs (or such parts of them as it appeared advisable), both night and 
day, even during the sleep of the patient, and the result has been suc- 
cessful in proportion to the care and energy employed. It may be well 
also to notice, that the only parts to which voluntary power of motion 
had not returned when the application of electricity was discontinued, 
were the fingers and lesser toes, parts most distant from the nervous centre, 
in which the capillary circulation was necessarily difficult, and from which 
a very remarkable amount of moisture was constantly exhaling, attended 
of course with constant evaporation and tendency to reduction of tem- 
perature." 



SLEEPLESSNESS. 383 

SLEEPLESSNESS. 
LECTURE XXXIV. 

Sleeplessness — Sleeplessness from anxiety, grief, &c. — Case of jaundice accompanied by sleep- 
lessness ; treatment — Remarks on purgative mixture* — On the proper time for admin Uteri rig 
opiates — Sleeplessness in delirium tremens — Chronic variety of delirium tremens ; treatment 
— Sleeplessness in fever; case — Failure of different modes of treatment — Use of o 
injections — Delirium traumaticum — Constitutional irritation from blisters; treatment — 
Sleeplessness in hypochondriacs and hysterical females — On the use and abuse of cold appli- 
cations to the head. 

Two cases which have been recently under treatment in this hospital 
demand your particular attention, — the man who has been labouring under 
a severe attack of jaundice, and the boy who is recovering from fever. 
A remarkable symptom in both of these patients, and which must have 
repeatedly attracted your notice, was a total privation of sleep. In the 
former case the sleeplessness continued for a week, in the latter for nine 
or ten nights. 

Sleeplessness is a very curious result of disease. It accompanies cer- 
tain morbid conditions of the system brought on by active disease or by 
grief, care, and various other forms of mental disturbance, continues to 
harass the unhappy sufferer night after night, and frequently resists the 
most powerful and decided narcotics. I do not intend to enter into any 
inquiry respecting the different states of the constitution in which it oc- 
curs ; my purpose is merely to offer a few practical remarks on the more 
obvious and striking examples, with the view of illustrating the cases to 
which I have directed your attention. 

There is a form of sleeplessness which is frequently the precursor of 
insanity, and which has been well described by my friend, Dr. Adair 
Crawford. The watchfulness in such cases is accompanied by the well- 
known symptoms of incipient mental derangement, and its treatment is 
therefore inseparably connected with that usually resorted to in cases of 
threatened insanity, and embraces the employment of means, moral as 
well as physical. Of these it is not my intention to speak ; 1 may observe, 
however, that Dr. Crawford has found opium, gradually increased to very 
large and frequently repeated doses so as to produce sleep, the best 
remedy. 

In the case of jaundice, the patient passed several nights wilhout any 
sleep. He was just beginning to recover from the jaundice when this 
new symptom appeared, and I directed your attention particularly to the 
circumstance, because every manifestation of nervous derangement con- 
nected with jaundice should be carefully watched. It frequently happens 
that jaundiced patients sleep too much, and in some cases the disease is 
accompanied by convulsions, succeeded by coma, most alarming symp- 
toms, and almost invariably the harbinger of a fatal termination. Dr. 
Marsh was the first who directed our attention to the great fatalitv of (hose 
cases of jaundice in which convulsions occur ; I have seen but one instance 
of recovery. It was in the case of a gentleman labouring under icterus, 
very considerable hepatitis, with enlargement of the liver and anasarca, 



384 CLINICAL MEDICINE. 

with ascites. He was treated by Dr. Osborne and myself, and had at 
least a dozen long and violent convulsive paroxysms, ending in coma, 
succeeded by temporary forgetfulness and fatuity. Repeated leeching of 
the right hypocbondrium, active purgation, and mercurialization of the 
system removed all the symptoms of disease, and he slowly but perfectly 
recovered. A very able and original writer, Dr. Griffin, of Limerick, 
has detailed the particulars of some interesting cases of this nature in the 
Dublin Medical Journal. You perceive, therefore, that in jaundice every 
thing denoting an unusual state of the nervous system, whether it be too 
much sleep or too little, demands your attention. 

In this man's case the jaundice was the result of an attack of hepatitis. 
We treated it with leeches, blisters, and the use of mercury, and in the 
course of a few days the stools became copiously tinged with bile, and 
symptoms of improving health appeared. At this stage, the dejections 
being bilious, but the jaundice still remaining, he began to exhibit symp- 
toms of restlessness and nervous irritability, and finally became perfectly 
sleepless. Here, gentlemen, we had to deal with a new symptom, ex- 
tremely harassing to the patient, and likely to react unfavourably on the 
original disease. As a preliminary step, I determined to evacuate the 
bowels, and for this purpose I prescribed a purgative draught, consisting 
of five ounces of infusion of senna, half an ounce of sulphate of magnesia, 
a drachm of tincture of senna, and a scruple of electuary of scammony. 
My object was to purge briskly, and then give a full narcotic. In all cases 
of jaundice depending on hepatic derangement, after you have succeeded 
in producing bilious evacuations, you should never omit prescribing an 
active aperient every second or third day for the space of ten days or a 
fortnight, with the view of carrying off the remains of the disease so as to 
prevent the occurrence of a relapse. Hence you will find such cases very 
much improved by the use of Cheltenham water, taken every day for 
three or four weeks after- the reappearance of a bilious tinge in the alvine 
discharges. The stimulus of the purgative causes an increased flow of 
bile into the intestines, which removes the hepatic congestion, and carries 
off what is popularly termed the dregs of the disease, and promotes a 
rapid and complete recovery. It is a simple, but successful practice, 
and I would advise you never to omit its employment in cases of this 
description. 

With respect to purgative mixtures, I may observe that you should 
prescribe a larger quantity of the infusion of senna than is generally 
ordered, if you wish to secure its certain and decided operation on the 
intestines. Hospital nurses, who reason from facts and experience, know 
this, and when directed to give a senna draught, they always give a small 
teacupful. They administer from four to six ounces at a time, and I have 
observed that in this way the action of the medicine is more certain, and 
the benefit derived from it more extensive. I am convinced that the 
usual mode of giving this valuable purgative in private practice is bad ; 
the quantity given is too small, and consequently it is necessary to repeat 
the dose several times, a mode of proceeding apt to occasion much nau- 
sea and griping ; I would, therefore, recommend a quantity varying from 
three to six ounces, to be administered in all cases where the patient's 
condition will admit of free purging. A most accurate observer of the 
effects of medicines, Mr. Kirby, is in the habit of ordering purgative 
mixtures in chronic cases to be taken at bed-time, and not, as is usually 



SLEEPLESSNESS. 385 

done, in the morning. He asserts that their action is milder and less 
irritating to the bowels when the patient lies in bed and is asleep until 
the period of their operation, than if he were up and about. 

After the purgative had produced four copious discharges, I prescribed 
eight minims of black drop, to be taken at a late hour in the evening. 
Whenever I give opiates to procure sleep, I always observe the rule laid 
down by Dr. M'Bride (a celebrated physician of this city), to select the 
period at which nature usually brings on sleep, and which varies accord- 
ing to circumstances and the habits of the patient. Whenever you have 
to deal with watchfulness in patients labouring under morbid states of the 
constitution, as, for instance, hectic, inquire when the tendency to sleep 
usually occurs, and administer your narcotic about an hour or two before 
its occurrence. It is between three and five o'clock in the morning that 
the inclination to sleep is strongest ; it is about this time that sentinels 
are most apt to slumber at their post, and consequently attacks upon 
camps or cities, made with the intention of effecting a surprise, are usually 
undertaken about this period of the morning. How well marked is the 
periodic tendency to sleep at this hour in all patients labouring under 
hectic fever produced by whatever cause. How often do we hear the 
poor sufferer complain of restlessly tossing about in his bed until three or 
four o'clock in the morning, when at last sleep, welcome though uneasy, 
for a few hours separates the patient from his pains. If given at an early 
hour in the evening, the effect of the opiate is not coincident with this 
periodic attempt of the constitution, and it fails in producing sleep ; but 
if exhibited at a late hour, it begins to produce its soporific effect at the 
very time when nature inclines the harassed sufferer to repose, and the 
result of these combined influences is a deep, tranquil, and refreshing 
sleep. By observing this simple rule, I have often succeeded in producing 
sleep in cases where various narcotics had not only failed, but even added 
considerably to the irritation and discomfort of the patient. 

In cases of sleeplessness where you have administered an opiate with 
effect, be careful to follow it up for some time, and do not rest satisfied 
with having given a momentary check to the current of morbid action. 
To arrest it completely, you must persevere in the same plan of treatment 
for a few days, until the tendency to sleep at a fixed hour becomes deci- 
dedly established. You must give an opiate the next night and the night 
after, and so on for five or six nights in succession ; and where the watch- 
fulness has been of an obstinate and persistent character, narcotics must 
be employed for a longer period and in undiminished doses. I do not 
allude here to the sleeplessness which accompanies confirmed hectic and 
other incurable diseases ; such cases require a particular mode of treat- 
ment, and generally call for all the varied resources of medicine. But in 
those instances of watchfulness, which are frequently observed towards 
the termination of acute diseases, it is always necessary to repeat the 
opiate for some time after you have succeeded in giving a check to this 
symptom. You need not be afraid of giving successive opiates, lest the 
patient should become accustomed to them, and a bad habit be generated, 
for the rapid convalescence and renewed health, which are wonderfully 
promoted by securing a sound and refreshing sleep, will soon enable him 
to dispense with the use of opiates. 

Another disease in which sleeplessness is a prominent symptom, is deli- 
rium tremens. We have had an example recently in our wards, and you 
26 



386 CLINICAL MEDICINE. 

have seen the means employed to overcome it. The patient came into 
hospital with symptoms of extreme nervous excitement and watchfulness, 
which had continued for some time, and were brought on, as is most com- 
monly the case, by repeated fits of intoxication, succeeded by a pause of 
perfect sobriety — in Irishmen the result of necessity or accident. In this 
man you must have remarked the signal benefit which attended the use 
of a combination of tartar emetic and opium, and how rapidly the watch- 
fulness disappeared. 

There is, however, one form of nervous irritability, frequently observed 
in persons who are in the habit of drinking freely, but without running 
into excess, and presenting, as it were, a shadow of delirium tremens, on 
which I shall make a few remarks. This curious state of the nervous sys- 
tem is generally found to exist in men about the middle period of life, and 
who consume a larger quantity of spirituous liquors than they are able to 
bear. Such persons, without suffering in appearance, or losing flesh, get 
into a chronic state of disturbed health, manifested by nausea, and even 
dry retching in the morning, loss of appetite, and impaired digestion ; but 
in particular by a deranged and irritable state of the nervous system, and 
by watchfulness. This forms one of the most distressing symptoms, and 
the patient generally complains that he cannot get any sound and refresh- 
ing sleep, that he lays awake for hours together, and that when he slum- 
bers his rest is disturbed by disagreeable dreams, or broken by slight 
noises. How are you to treat this affection? I can give you a valuable 
remedy for this deranged state of constitution — one which I have often 
tried, and which, from experience, I can strongly recommend. It is a 
mixture composed of tincture of columba, quassia, gentian, and bark — say 
an ounce of each; and to this is added a grain, or even two, of morphia. 
A compound tincture, somewhat analogous to this, is much in use among 
military gentlemen, and others, who have resided for a considerable time 
in India, where, from the heat of the climate, and the prevalence of intem- 
perate habits, the stomach becomes relaxed and the nervous system irrita- 
ble, so as to represent, in a minor degree, the symptoms which characte- 
rise delirium tremens. You perceive I combine several tonics to form 
this mixture, because they are well known to produce a more beneficial 
effect when combined than when administered singly ; and I add to these 
a narcotic, which has the property of allaying nervous excitement without 
derangement of the intestinal canal. The dose of this mixture is a tea- 
spoonful three or four times a-day, and the best time for taking it is about 
an hour before meals. It gradually removes the nausea and debility of 
stomach, lessens nervous irritability and watchfulness, and with a proper 
and well-regulated diet, and attention to the state of the bowels, I have 
seen it produce excellent effects. In such persons much benefit is derived 
from the use of the tepid shower bath. 

Fever is another disease in which sleeplessness is a symptom, frequently 
of an unmanageable character, and pregnant with danger to the patient. 
You witnessed this in the case of the boy who lies in the small Fever 
Ward, next to the man who is at present labouring under general arthritis. 
This boy had fever of a mild description, and unattended with any bad 
symptoms. His case scarcely required any attention, and he had almost 
arrived at a state of convalescence without the aid of medicine, when he 
began to lose his rest, and absolutely became sleepless for several nights. 
I beg your attention to this case for many reasons. In the first place, you 



SLEEPLESSNESS. 387 

have seen that we tried many remedies without success, and afterwards 
fortunately hit on one which answered our purpose completely. Let us exa- 
mine thenatureof the medicinesprescribed,and our reasonsfor giving them. 

In the first place we gave, as in the case of jaundice, an aperient fol- 
lowed by a full dose of black drop. It failed in producing any sleep ; we 
repeated it a second and a third time, but without the slightest benefit. 
I then remarked to the class, that, as I had noticed the good effects result- 
ing from a combination of tartar emetic and opium in the case of delirium 
tremens where opium alone failed in procuring sleep, it would be proper 
to give this remedy a trial. I observed, at the same time, that I was con- 
vinced that the preparations of antimony have a distinct narcotic effect, 
and that I had seen patients in fever whose watchfulness had been re- 
moved by antimony given in the form of tartar emetic or James's powder. 
I said it was my firm impression that tartar emetic, along with its other 
effects, exerts a decided narcotic influence on the system, and that it is this 
which makes it so valuable a remedy in treating the sleeplessness of fever 
and delirium tremens. Our predecessors were much in the habitof using an- 
timonial mixtures in the treatment of fever; and they did this because they 
knew, by experience, that these remedies worked well. It is at present 
too much the fashion to decry their practice, and in this instance, I think, 
with very little justice. 

In this boy's case, however, the combination of tartar emetic and opium 
did not succeed in producing sleep. Having thus failed in our first and 
second attempts, we had recourse to the liquor muriatis morphiae — a pre- 
paration first brought into use by Dr. Christison, and which, in the form 
usually employed, is equal in strength to laudanum. It is an exceedingly 
valuable preparation for many reasons, and one which has the strongest 
claims to your notice. Being of the same strength as laudanum, it saves 
the trouble of learning and remembering new doses, and, in addition to 
this, it possesses the more important advantages of inducing sleep with 
more certainty, and not acting as an astringent on the bowels, or affecting 
the head so frequently as laudanum. You observe that I say so fre- 
quently ; I do so because cases now and then occur in which even mode- 
rate doses of the liquor of the muriate of morphia produce quite as much 
headache as laudanum. I prescribed the former in doses of fifteen drops 
every six hours, so as to give sixty drops in the day, and continued this 
practice for two days, but without the slightest effect. Here you see 
three modes of inducing sleep completely failed. The boy remained for 
a day without taking any medicine, and then we made another attempt, 
which was more successful. We first prescribed a purgative enema, and 
after this had operated he was ordered an opiate injection, consisting of 
four ounces of mucilage of starch and half a drachm of laudanum. He 
fell asleep shortly after using the opiate injection, and did not awake until 
the next morning. The following night the opiate was repeated in the 
same form, and with equal success ; convalescence went on rapidly, and 
the boy's health is now quite re-established. 

Here, then, is a singular fact attested by this case, that opiates in the 
form of injection will succeed in producing sleep, where they have com- 
pletely failed when administered even in large and repeated doses by the 
mouth. Baron Dupuytren was the first who made this important obser- 
vation, and proved that narcotics applied to the mucous surface of the 
rectum exercise a powerful influence on the nervous system, always 



388 CLINICAL MEDICINE. 

equal, and very often superior, to the effect produced by taking them 
into the stomach. He maintains that, in delirium traumaticum and de- 
lirium tremens, a certain quantity of opium, when prescribed in the 
form of enema, will act with more decided effect in allaying nervous 
excitement than the same or even a larger quantity, when taken by 
the mouth. I have no hesitation in giving full credit to this asser- 
tion, as the results of my experience tend strongly to confirm' its truth. 
I have, not long since, published, in the Dublin Medical Journal, 
the case of a patient in Sir P. Dun's Hospital, who was reduced to the 
last stage of debility and emaciation from effects of mercury and syphilis. 
The torture which this man endured from nocturnal pains, and a total 
deprivation of sleep, was such that he swallowed enormous doses of 
opium ; in fact, he had, previously to his admission into Sir P. Dun's 
Hospital, exhausted all his means in purchasing opium. While in hos- 
pital, he used to take 150 drops of black drop in the course of a day, and 
yet, notwithstanding these excessive doses, he could only get a few 
minutes of unrefreshing slumber. After some time I changed the plan of 
treatment, and had the black drop administered in the form of enema. It 
succeeded in producing a decided soporific effect, and in a short time he 
was able to enjoy a sufficient quantity of repose, from taking only one- 
tenth of the quantity used by the mouth. I have also, in the same paper, 
adverted to the case of a medical gentleman who laboured under an affec- 
tion of his joints, which was accompanied by spasms of the limbs and 
most excruciating pains. His agony was so intense that he used to 
swallow grain after grain of opium, until he had taken to the amount of 
thirty or forty grains, with the view of procuring some alleviation of his 
sufferings. He was prevailed on to give up altogether the use of opium 
by the mouth, and employ it in the form of enema, which he did with 
the most striking advantage — the quantity which succeeded in giving 
relief in this w T ay being scarcely the twentieth part of what he ordi- 
narily used. 

It is unnecessary for me to enter here into any discussion with respect 
to the nature and treatment of delirium traumaticum, and the sleepless- 
ness which always accompanies it, as you will find this subject very ably 
treated in M. Dupuytren's works, and in a very instructive and elegant 
lecture delivered by Sir Philip Crampton (the surgeon-general) in this 
hospital, and published in the last volume of the London Medical and 
Surgical Journal. There is, however, one kind of sleeplessness, arising 
from irritation of the skin produced by blisters, which frequently assumes 
a very serious character, and on which it may be necessary to offer a few 
observations, as the subject has not been noticed sufficiently by practical 
writers. Trifling as the irritation resulting from a blister may seem, yet, 
under certain circumstances, it is a symptom of highly dangerous aspect, 
and becomes a source of just alarm. I have witnessed the loss of some 
lives from this cause, and many patients have, to my knowledge, been 
rescued from impending danger, by an early and proper share of attention 
being directed to its phenomena and treatment. 

The bad effects on the nervous system, occasionally produced by the 
application of blisters, are somewhat analogous to those which result from 
wounds and other external injuries, and to be accounted for on the same 
principle. Wounds and injuries sometimes make an impression on the 
nervous system, by no means proportioned to the importance of the injured 



DELIRIUM TRAUMATICUM FROM BLISTERS. 389 

organ to life, or the extent of the mischief. An injury, produced by a 
body which strikes the sentient extremities of the nerves with great force, 
will sometimes produce very remarkable effects on the system. Thus, a 
musket-ball striking a limb may, without wounding any great artery or 
nerve, or destroying any part of importance to life, produce a train of 
nervous symptoms of an extraordinary character. The person, without 
feeling much pain, and scarcely knowing that he has been wounded, 
without being terrified or having his imagination excited by any appre- 
hended dangers, turns pale, gets a tendency to faint, and sometimes 
actually dies from an impression made on the nervous system. In the 
same way an external injury reacting on the nerves may bring on high 
mental excitement, delirium and a total privation of sleep, as we see 
exemplified in delirium traumaticum. I mention this with the view of 
establishing the proposition, that impressions made on the sentient ex- 
tremities of the nerves are sometimes reflected on the nervous centres, 
producing the most alarming effects. In this way we can understand 
how the irritation of blisters may produce sleeplessness, mental aberration, 
and a train of symptoms analogous to those which characterize delirium 
traumaticum. 

The delirium and sleeplessness arising from the irritation of blisters is 
by no means an uncommon disease. I have seen many examples of it in 
private practice, and 1 am anxious that you should be acquainted with its 
nature and treatment. It is generally met with in the case of children, in 
whom the cutaneous surface is extremely tender and irritable. I could 
relate several instances in which I have been called on to visit children 
labouring under fever, where symptoms of high nervous excitement were 
present, and where I found the little patients delirious, screaming, and 
perfectly sleepless from this cause. I have found this alarming affection 
generally occurring at an advanced stage of fever, and exhibiting a train 
of symptoms which closely resemble hydrocephalus. I have observed 
that after the application of a blister to relieve some suspected cerebral or 
abdominal or thoracic affection, jactitation, restlessness, constant applica- 
tion of the hand to the head, and delirium have appeared, and that these 
symptoms had been mistaken for incipient cerebritis or hydrocephalus, 
and treated with leeches and purgatives. When the blister has been 
applied to the nape of the neck, the soreness and irritation of the skin on 
that part cause the child to roll its head from side to side on the pillow with 
that peculiar motion and scream supposed to prove to a demonstration the 
existence of hydrocephalus. I have learned, also, that the above measures, 
so far from giving relief, have only tended to produce an exacerbation of 
the disease, and that the medical attendant has given up the case in de- 
spair. Now, gentlemen, if called to such a case, what should be your 
practice ? In four cases of this kind I gave my opinion frankly to the 
medical attendant, and told him he was pursuing a wrong course, that the 
disease was analogous to delirium traumaticum, and not to be treated by 
leeches or purgatives, and least of all by blisters. I observed to him that 
these symptoms had made their appearance shortly after the child had 
been blistered for suspected disease of the belly, or head, or chest ; and 
that it was useless to attempt to remove the disease by leeches, or purga- 
tives, or blisters. The remedy I always proposed was opium, and it was 
acknowledged in four or five cases, that this remedy had succeeded not 
merely in relieving the existing symptoms, but in saving the patient's 



390 CLINICAL MEDICINE. 

life. In such cases, particularly in young children, the opium must be 
given in small but frequently repeated doses, so as to insure its energetic 
but safe action, and the greatest care must be taken to soothe the irritated 
portion of the skin by ointments, poultices, &c, while unwearied diligence 
must be bestowed upon the task of preventing the child from scratching the 
blistered surface. To effect this the child's hands must be muffled in ap- 
propriate gloves, and must be secured in the sleeves of a shirt' made for 
the purpose. 

I beg your attention still further to this subject of sleeplessness and de- 
lirium. I wish to mention the case of a gentleman who was a pupil of 
mine. This gentleman studied hard, attended lectures regularly, and was 
constantly in the dissecting-room. While thus occupied, he happened to 
wound one of his toes in paring a corn, and afterwards wore a tight shoe 
on the injured foot. A small imperfect abscess formed in the situation of 
the corn, which was opened by one of his fellow-students: the incision 
gave very great pain, and was not followed by any discharge of matter. 
Next day he was feverish, and the lymphatics of the injured limb became 
extensively engaged, the inflammation ascending towards the glands of 
the groin and having a tendency to form a chain of insulated patches in 
different parts of the leg and thigh along the course of the lymphatics. 
This you will generally find to be the case in inflammatory affections of 
the lymphatics ; the inflammation is seldom continuous, but in the majo- 
rity of cases, is developed at certain insulated points, where small diffuse 
suppurations form very rapidly. After a few days, this young gentleman's 
fever increased to an alarming height, he became completely sleepless, 
and had incessant delirium. He was purged briskly, leeched extensively 
and repeatedly, his head shaved, and cold applications so constantly ap- 
plied, that he appeared half drowned and collapsed. Notwithstanding 
this very active treatment not the slightest relief was obtained ; neither 
were the symptoms mitigated by incisions made in the inflamed patches 
for the purpose of evacuating matter ; the sleeplessness continued, and the 
delirium was as wild as ever. I saw him on the seventh or eighth day, 
when all antiphlogistic measures had failed, and his friends were quite in 
despair. On being asked my opinion, I stated that I looked upon the 
case as one of delirium, not proceeding from any determination to the 
head or inflammation of the brain, but depending on a cause analogous 
to those which produce delirium traumaticum, and that instead of anti- 
phlogistics I would recommend a large dose of opium and some porter to 
be immediately given. Mr. Cusack, who visited the patient after me, 
concurred in this view, and a full opiate was administered in repeated 
doses. It succeeded in producing sleep and tranquilizing the nervous 
excitement. I may here observe that a few days afterwards this gentle- 
man had a return of the symptoms of cerebral disturbance with sleepless- 
ness, in consequence of omitting his opiate, and that the opiate and porter 
were again administered, and again succeeded in removing the delirium 
and watchfulness. By perseverance in the use of the same means, the 
disease was completely removed, and convalescence established. 

The last kind of sleeplessness to which I shall direct your attention, is 
that which is frequently met with in persons of a nervous and irritable 
disposition, in hypochondriacs and hysterical females. You will find 
such persons, although of active habits and with tolerable appetites, com- 
plaining of a total privation of their natural rest, and it is astonishing to 



COLD LOTIONS TO THE HEAD. 391 

think how long they may continue subject to this harassing watchfulness. 
I have frequently observed this affection among females of nervous habit, 
who possessed strong feelings of attachment to the interest and welfare of 
their families, and who were remarkable for an exemplary and over 
anxious discharge of their domestic duties. It is also very often met with 
in the upper classes of life, where the susceptibility to nervous excitement 
is morbidly increased by fashionable habits. I shall not enter into the 
various moral causes which tend to produce this state of the nervous sys- 
tem, and will content myself for the present with giving you some hints 
for the treatment of this obscure affection. As yet I have not any distinct 
and accurate notions of the disease, and can only guess at the treatment ; 
but this much I may state, that such cases are not to be cured by the 
means which I have already detailed. If they are to be cured by any 
means, I think it is by antispasmodics, and remedies which have a gen- 
tle stimulant, and, if I may so express myself, alterative effect on the 
nervous system. I have cured two cases of this kind by musk and assa- 
fcetida, where every other remedy had failed. To one of these I was 
called by my friend, Dr. Neason Adams ; the patient was a lady of deli- 
cate constitution and hysterical habit; she was emaciated, and suffered 
from a total loss of* rest, but had no other disease. All kinds of narcotics 
had been tried unsuccessfully, and opium in all its forms had failed in pro- 
curing sleep. I advised the use of musk in doses of a grain every second 
hour, and this means proved eminently successful. In another case I suc- 
ceeded by administering the same remedy in combination with assafoetida. 
I have also remarked that assafoetida alone, given in doses of two or three 
grains three times a-day, has very considerable effect in calming ner- 
vous irritation of this description, and restoring the patient to the enjoy- 
ment of more prolonged and refreshing sleep. In all such cases the 
physician must be most careful to have the appearance of not thinking the 
loss of sleep as a matter of much consequence, and the family of the 
patient must be directed to speak as little about the matter in his presence 
as possible ; — nay, so powerful is the operation of moral impressions, that 
in one case, which I attended along with Mr. Halahan, I succeeded in 
procuring sleep by ordering a musk pill to be given every second hour 
night and day, and by desiring the patient to be awakened, should she be 
asleep, at the time the pill was to be taken. I laid great stress on the 
importance of so proceeding, and thereby produced so strong an effect on 
the patient's mind, and inspired so great a confidence in the efficacy of 
the medicine, that she w T ent to bed, not so much afraid of lying awake as 
afraid of being asleep at the hours when she ought to take a pill. The 
idea which had hitherto fixedly occupied her mind was displaced by a 
new impression, and relief was obtained the very first night. 

In affections of the head occurring in acute diseases, and attended with 
raving and loss of rest, it is a very usual practice to direct the application 
of cold lotions to the shaved scalp. 

Permit me, gentlemen, to make a few remarks upon this important sub- 
ject. I wish I could make myself well understood on this point, for I 
have seldom met with any person who seemed to bear in mind the true 
principle upon which cold is applied as a means of repressing local heat. 
In cases of determination of blood to the head occurring in fever, the 
common practice is to have the head shaved and cold lotions applied. 
Enter the room of a patient who is using cold applications, and you will 



392 CLINICAL MEDICINE. 

observe the process conducted with great apparent nicety ; the head is accu- 
rately shaved and carefully covered with folds of linen wet with a lotion 
to which spirit of rosemary or some odoriferous tincture has communi- 
cated an agreeable and refreshing smell ; but when you come to examine 
the patient, you find his head smoking and the heat of his scalp increased. 
The nurse applies the lotion once every half hour, or perhaps not so often ; 
indeed, she seldom repeats the application until her notice is attracted by 
the steam rising from the patient's head, or until she herself, awaking 
from a comfortable sleep, and going over to examine the state of the 
patient's head, finds the folds of linen which cover it as hot and dry as if 
they had been hung before a fire. Whether applied to reduce local 
inflammation in any part of the body, or to cool the scalp in determina- 
tion to the head, cold lotions as ordinarily employed do infinitely more 
harm than good. The cold is applied at distant intervals, its effect soon 
ceases and reaction constantly takes place, leaving the part as hot or even 
hotter than it was before. 

If you put your hand into snow for a few moments, and then take it 
out, it quickly resumes its natural heat; and if you repeat this at consider- 
able intervals, so as to give time for reaction to occur, the vessels assume 
a more energetic action, and it becomes hot and burling. If you con- 
tinue to keep it in the snow for a long time, its heat becomes completely 
exhausted, reaction does not take place until after a considerable period, 
and very slowly, and the hand remains at very low temperature for a good 
while. Bear this in mind, for it will direct yon in the application of cold 
to reduce local heat. If cold applications be used at such intervals as to 
allow the scalp to react and resume its heat, rely upon it, it is much 
better to forbid them altogether. Where you wish to apply cold with 
effect, let it be done by relays of folded linen, wet with any frigorific mix- 
ture, and repeatedly applied to the scalp so as to leave no smoking, or, 
what is much better, get three or four bladders, put into each a quantity 
of pounded ice, and apply one over the crown of the head, one on each 
side, and lay one on the pillow for the back of the head to rest on. 

There is a vast difference between a thing being done and its being 
well done : so it is with regard to cold lotions ; so difficult is it to insure 
their proper application, that I have entirely given them up in hospital 
practice, and rarely order them in private. I have been induced to 
abandon them in consequence of witnessing so many instances in which 
my directions were neglected, and consequently the cerebral congestion 
was augmented by their malapplication. Another serious inconvenience 
frequently arises from their use when applied in a slovenly manner, 
which is the danger of cold arising from the pillow and bed-clothes being- 
wetted. 

It is a curious fact that the head is the only one of the three cavities 
with respect to which long-established custom has laid down the maxim, 
that when its contents are inflamed we may cool the surface over it, while 
in inflammatory affections of the thoracic or abdominal viscera this practice 
is avoided as dangerous and inapplicable. Latterly, however, some me- 
dical men have been inclined to question the grounds on which cold 
applications have been rejected in the two latter cases, and some have 
even declared that they have used ice poultices in inflammation of the 
chest and belly with great success and perfect safety. I am not as yet 
prepared to adopt this practice, although I must confess that a review of 



SLEEPLESSNESS. 393 

the subject might incline me to give up my prejudices on this point. It 
is certainly but reasonable to think that what is true of the one may be 
also true of the other, and that the application of cold to the head and 
heat to the chest and belly has nothing in its favour beyond mere custom. 
It should be recollected, however, that the head and face are more accus- 
tomed to cold than the chest and belly, and hence are less liable to any 
mischief likely to arise from its application in an intense degree. Still, I 
am inclined to think that there is much prejudice connected with the 
practice of applying cold to the head ; and I have very little doubt that 
if the matter was properly investigated, and a number of experiments 
made, it would lead to the abandonment of cold applications in most 
inflammatory diseases of the brain. In fevers, I can say positively that 
in the majority of cases they are certainly injurious, as usually applied ; 
sponging the bare scalp with tepid or warm vinegar and water, or even 
frequently repeated steeping of the head and temples, will often succeed 
much better in abating the headache and restlessness of fever than any 
cold applications whatsoever. In 1832, a violent influenza, accompanied 
by most distressing headache, attacked thousands in Dublin ; this intense 
pain in the head was relieved by nothing so effectually as by diligent 
steeping of the temples, forehead, occiput, and nape of the neck, with 
water as hot as could be borne. 

I do not speak here of the application of cold to the head for the pur- 
pose of relieving local heat and inflammation, but to produce an effect on 
the whole system. Cold thus applied is of decided and unequivocal 
value. You are aware that in cases of fever accompanied by symptoms 
of high mental excitement and great heat of skin, the use of cold dashing 
has produced the most extraordinary effects. Again, if a patient has taken 
too large a dose of prussic acid or any other narcotic, the best mode of 
rousing him is by pouring water on his face or chest from a height. In 
Turkey, if a person happens to fall asleep in the neighbourhood of a 
poppy field, and the wind blows over it towards him, he becomes gradu- 
ally narcotised, and would die, if the country people, who are well ac- 
quainted with this circumstance, did not bring him to the next well or stream, 
and empty pitcher after pitcher on his face and body. This occurred to 
my friend Dr. Oppenheim, during his residence in Turkey, and he owes 
his life to this simple but effectual treatment. 

To conclude, gentlemen, I may observe that sleeplessness in a chronic 
form is often produced by dyspepsia, and can only be relieved by the 
means suited to indigestion. Here it is that small doses of blue pill and 
tonic purgatives are of infinite service, combined with change of air, of 
scene, and an appropriate diet. In many females, sleeplessness is com- 
bined with menstrual irregularity, and can only be cured by means calcu- 
lated to invigorate the health and restore the catamenial discharge to its 
natural periods and quantity, for the nervous system suffers equally 
whether they be suppressed or overabundant. It is singular how long 
sleeplessness often continues in chlorosis without inducing those serious 
consequences that are produced by this symptom in other morbid states 
of the system. In such cases much is sometimes accomplished by means 
of the common preparations of morphia, or by the use of Hoffman's liquor 
(liquor sethereus oleosus), camphor, and other medicines that act upon the 
nervous system. It must be confessed, however, that these and every 
other expedient to obtain sleep often fail in chlorotic and hysterical females, 



394 CLINICAL MEDICINE. 

in whom relief is only obtained by a gradual improvement of the general 
health and menstrual function. 

Postscript. — Having in the preceding lecture alluded to the danger to 
be apprehended when any nervous symptom arises in a case of jaundice, 
I shall illustrate this view by introducing some very remarkable instances 
of this form of disease. The three following cases were sent to me by 
my friend Dr. Hanlon, of Portarlington, and are the more valuable as the 
author never expected their appearance in this work. With respect to 
the writer I can say, that during his pupilage he was remarkable for ex- 
treme diligence, assiduity, and zeal in the pursuit of professional know- 
ledge ; and I hope that my readers wilt value as I do his communication. 

Case 1 — " Saturday, July 25, 1840, I was called to visit Miss Maria 
B , aged seventeen years. I was informed that she had been pre- 
viously healthy. On the preceding Wednesday she complained of languor, 
and in a few hours was attacked with bilious vomiting, which had returned 
three or four times in every twenty-four hours since. When the vomiting 
commenced, she became jaundiced, and the colour increased in intensity 
until it assumed a greenish-yellow tint. The bowels were constipated for 
two days before the vomiting began, and had remained so notwithstand- 
ing that the apothecary in attendance had given her repeated doses of 
purgative medicines. Effervescing draughts and other means intended to 
allay the vomiting had been given without success. 

" I found the tongue thickly coated w r ith a yellow mucus ; tenderness 
of the epigastrium and right hypochondrium ; thirst; abdomen not tender 
on pressure ; urine scanty and high-coloured ; pulse 80 ; slight headache ; 
pupils natural ; complains of want of sleep ; and appears fretful and 
anxious. 

" Calomel combined with compound extract of colocynth and croton 
oil internally, aided by purgative enemata, caused a dark, small and offen- 
sive motion towards evening. Leeches were applied to the epigastrium 
and region of the liver, followed by stupes, three grains of calomel every 
fourth hour, and a purgative draught consisting of infusion of senna, and 
tincture of senna, jalap and cardamons after every second dose of calomel. 

" Sunday — Vomited twice since yesterday evening ; the bilious matter 
of a darker colour ; tongue still loaded ; thirst diminished ; tenderness of 
epigastrium and right hypochondrium much less ; bowels moved twice in 
the course of the night — motions larger but still very dark in colour; 
pulse 80; headache relieved; pupils natural; colour of skin the same; 
slept for two or three hours in the night ; same treatment continued. 

" Monday morning, 5 o'clock — I was called up in haste to visit her. 
It appeared that two hours before my arrival she complained of violent 
headache and intolerance of light, vomited a dark brown matter resembling 
coffee grounds; soon afterwards became very restless, and gradually fell 
into a state of stupor. I found her in imperfect coma, the pupils exces- 
sively dilated and insensible to light, the eyelids closed. She flung her- 
self every minute or two from one part of the bed to another, and uttered 
a faint subdued scream ; she was very unwilling to be interfered with ; 
pulse 60 and oppressed ; skin of a still deeper tint of greenish-yellow. 

" The assistance of Dr. Tabuteau and Dr. I. Jacob was procured in 
consultation. Fourteen leeches were applied to the temples ; the head 
shaved and cold cloths applied to it ; twelve grains of calomel in the 



NERVOUS SYMPTOMS IN JAUNDICE. 395 

first dose, and five grains every second hour afterwards ; purgative enemata 
were employed every second hour. Cold affusion on the head was sub- 
sequently used, to a great extent, but without producing any change in 
the state of the pupils, or the coma ; mercurial inunction in the region of 
the liver and insides of the arms was commenced, and a large blister ap- 
plied to the scalp. 

"At 11 o'clock, a.m. — She was seized with violent convulsions, which 
lasted about a minute, and were accompanied with shrill screams; the 
right extremities appeared more strongly convulsed than the left, the 
mouth was drawn to the left side. The convulsions returned every thirty 
or forty minutes with same violence and screaming, until three o'clock, 
p.m., when they became less violent, but much more protracted in dura- 
tion, and gradually passed into a continued spasm, or jerking of the ex- 
tremities. She threw up occasionally a mouthful of the same dark matter 
which she had previously vomited. The administration of the calomel 
was relinquished, as every attempt to give it brought on a return of the 
convulsions. The mercurial inunction was assiduously continued, but no 
mercurial fetor could be detected on the breath ; the coma became more 
profound ; the pulse rose to 108, small, fluttering, and finally intermitting ; 
sordes collected on the teeth ; the urine and feces passed involuntarily ; 
the breathing, towards the close, became stertorous ; and she expired at 
11 o'clock the following morning. No examination of the body was per- 
mitted." 

Case 2 — "Monday, March 29, 1841, I was requested to visit Miss 

Charlotte B , aged 11 years; sister of the former. She had been 

previously healthy ; for the last two days has had the usual symptoms of 
a feverish cold, which is attributed to her having wetted her feet. T 
found the tongue loaded ; tenderness of the epigastrium, none in the region 
of the liver; thirst; bowels confined ; urine scanty and high-coloured; 
pulse 120; no headache ; pupils natural ; no discoloration of the eyes or 
skin. Six leeches to the epigastrium, to be followed by stuping ; purga- 
tives ; diaphoretic mixture and diluents prescribed. 

" Tuesday morning, 9 o'clock — Appears better ; slept some hours in 
the course of the night ; tongue cleaner ; thirst diminished ; tenderness 
of the epigastrium much less ; no tenderness on strong pressure in the 
right hypochondrium ; bowels have been strongly acted on four times ; 
motions dark and offensive ; urine more copious and paler ; pulse 92 ; no 
headache ; pupils natural ; no discoloration of the conjunctiva or skin. 
Having been absent from home during the day, I hastened, on my return 
at eight o'clock in the evening, to visit ; and was greatly surprised to find 
her in the same state as her sister had been. It appeared that about three 
o'clock she became heavy and languid, the skin became slightly jaun- 
diced. She complained of headache and intolerance of light ; vomited a 
dark-brown matter resembling coffee-grounds ; tossed about from one part 
of the bed to another ; refused to answer questions, and fell into a state 
of insensibility ; the bowels had been moved twice, the motions dark but 
not offensive. I found her in a state of imperfect coma, the eyelids closed, 
the pupils excessively dilated, and insensible to light; pulse 64 and op- 
pressed ; skin jaundiced. In a few minutes after my entering the room 
she was seized with violent convulsions, which w T ere accompanied by 
shrill screams, and lasted about a minute. Pressure on the right hypo- 
chondrium appeared to give her pain. Upon my requesting that addi- 



396 CLINICAL MEDICINE. 

tional medical aid should be procured, her friends declined having it, on 
the ground that the case appeared precisely the same as her sister's, and 
all our efforts on that occasion had been unavailing. Under these cir- 
cumstances I had recourse to the same plan of treatment as that adopted 
in the preceding case : cold affusion on the shaven head ; ten leeches to 
the right hypochondrium ; mercurial inunction on the right side and in- 
side of the arms, in the intervals between the convulsions ; strong purga- 
tive enemata frequently repeated, and a large blister on the scalp. The 
disease, quite uncontrolled by these means, pursued precisely the same 
course, in every particular, as the former one. The convulsions con- 
tinued most violent for two hours, when they began to be less violent, but 
much more protracted in duration, until they passed into continued Switch- 
ings of the muscles of the extremities. The coma became more profound ; 
the breathing stertorous ; sordes collected on the teeth ; and she expired 
at seven o'clock the following morning. 

" Her friends being now alarmed for the safety of her surviving brothers 
and sisters, became very desirous that the body should be examined. Dr. 
Tabuteau, who had seen the former case in consultation,' assisted me in 
making the examination. The following are the results : examination 
made 30 hours after death ; surface of the body jaundiced. 

" Head. — Pacchionian glands preternaturally vascular ; venous tumes- 
cence generally over the surface of the brain, with increased vascularity 
of the middle, and especially the left anterior lobes ; substance of the 
brain much more vascular than usual ; great vascularity of the choroid 
plexus ; none of the optic thalami, or corpora pyramidalia ; the entire 
surface of the base of the brain highly vascular, particularly at the crura 
cerebri, pons varolii, and medulla oblongata ; no fluid found in the ven- 
tricles. 

" Abdomen. — Numerous spots of extravasated blood in the omentum ; 
several small patches of inflammation along the small intestines ; stomach 
apparently healthy. 

" Liver. — Size, natural ; colour, externally of a dull yellow, with seve- 
ral dark spots about the size of a half-crown piece ; consistence, less than 
usual ; structure, minutely granular, and of a very peculiar crimson-orange 
colour, somewhat resembling what might be supposed to result from an 
intimate mixture of arterial blood and bile ;* gall-bladder distended with 
bile of the usual appearance. Thorax not examined. 

" I endeavoured to preserve portions of the liver in a dilute solution of 
corrosive sublimate and diluted alcohol, but they gradually lost their cha- 
racteristic appearance in both fluids." 

Case 3 — " Friday, June 18, 1841, 1 was called to visit Miss Jane B , 

aged eight years ; sister of the two former. I was informed that she had 
been previously healthy. This morning she appeared languid and was 
attacked with bilious vomiting. No cause can be assigned for her illness. 
I found the skin jaundiced slightly ; the tongue loaded ; tenderness of the 
epigastrium and right hypochondrium ; thirst ; bowels confined ; pulse 
108 ; no headache ; no intolerance of light ; pupils natural ; urine scanty 
and high-coloured. Eight ounces of blood were immediately taken from 
the arm, which afterwards proved to be cupped and buffed ; eight leeches 
applied to the region of the liver followed by stuping ; twenty grains of 

* This is very like the appearance of the liver described by Louis, as occurring in the fatal 
cases of yellow fever at Gibraltar. 



NERVOUS SYMPTOMS IN JAUNDICE. 397 

calomel given at once, and a strong purgative draught every fourth hour 
until the bowels are fully acted on ; three grains of calomel and one and 
a half of James's powder every third hour after purgation ; cold to the 
head. 

" Saturday — Slept none; skin more deeply jaundiced ; tenderness of 
the epigastrium diminished ; heat of the right hypochondrium still re- 
mains ; tongue yellowish ; vomited twice since yesterday evening ; urine 
tinged with bile and more copious ; bowels moved four times ; motions 
dark and offensive ; pulse 110 ; headache and some intolerance of light ; 
considerable restlessness. Six leeches to the right side ; four to the tem- 
ples ; cold to the head ; a blister to the nucha, mercurial inunction ; five 
grains of calomel and one of James's powder every second hour. I now 
watched the case with the greatest interest and anxiety. 

" Sunday evening — Slight mercurial fetor of the breath ; tongue be- 
ginning to clean ; tenderness of the right side diminished ; bowels moved 
three times; motions less dark and offensive ; pulse 90, and soft ; head- 
ache and intolerance subsided ; restlessness entirely gone ; some return 
of appetite. Calomel and James's powder were continued every fourth 
hour until a slight salivation was established and cold carefully applied to 
the head. No unfavourable symptoms subsequently appeared. The 
tongue became clean, the pulse fell to the natural standard, the motions 
became more healthy in appearance, the appetite returned, and under the 
use of four grains of calomel at night, and a strong dose of black draught 
the following morning, repeated every third night for three weeks, the 
jaundice disappeared, and she has remained quite well up to this period." 

CASE 4. JAUNDICE FROM INFLAMMATION OF THE GALL-ELADDF.R NER- 
VOUS SYMPTOMS DEATH — POST-MORTEM. 

" Anne Milton, a healthy fine young woman, aged 20 (servant), admitted 
into the Meath Hospital under Dr. Graves, November 1, 1841. About 
five weeks ago was attacked with pain in the right hypochondrium, ex- 
tending into the epigastrium, which lasted for a fortnight, and was followed 
by jaundice and high-coloured condition of the urine. She does not re- 
collect whether the feces were whiter than usual. After the skin got yel- 
low the pain in the side diminished ; but during the whole time it lasted 
she had constant vomiting and nausea. Three days after the setting in of 
pain, and ten before the appearance of the jaundice, she became affected 
with excessive itching of the skin, which prevented sleep ; this itching 
ceased as soon as the jaundice appeared.* She had no pain in either shoul- 
der. At the time the skin became yellow, an eruption of an herpetic cha- 
racter appeared over the hepatic region. She was under no treatment for 
the pain; but to the eruption, a mixture of gunpowder and blood was 
applied. 

"Present Symptoms. — Skin and conjunctiva deeply jaundiced; all ob- 
jects appear yellow-; urine high-coloured ; feces white; no itching of skin; 
the linen over the eruption is stained yellow; tongue clean and moist; 

* The same phenomenon was observed in a man named Jones, who laboured under the most 
severe jaundice, in whose case the itching preceded the appearance of the jaundice for two 
months, and discontinued on the discoloration of the skin becoming established. These two 
cases are irreconcileable with the generally received opinion, that the itching depends on the 
deposition of the constituents of the bile in the texture of the skin. 



398 CLINICAL MEDICINE. 

great thirst; appetite good; stomach not sick ; no pain after taking meals; 
bowels confined ; sleeps badly ; no headache ; pulse 80, full and soft; breath- 
ing hurried; no cough or physical sign of disease in either lung; the 
heart's action strong, but the sounds are normal and distinct; complains of 
no pain when the right hypochondrium is pressed, or when the ribs are 
pushed against the liver, but she has slight pain at a point between the right 
hypochondrium and epigastrium, greatly increased by pressure. There is 
some fulness of the latter region, but percussion does not give a dull sound ; 
no enlargement of the liver noticeable or detected by percussion; the ab- 
dominal muscles are very irritable, and are thrown into spasm by the least 
effort to examine the abdomen minutely; she has no pain over either lum- 
bar region. Poultices to the eruption — xii. leeches to the painful part. 
R. pil. hydrarg. gr. x. Pulv. doveri gr. v. in pil. iii. st. i. 4tis. horis. 
Enema purgans. 

"November 5th — pain relieved by leeches ; no other change ; appetite 
extremely good. 

" November 6th — was attacked last night with pain in the, stomach; no 
vomiting; pulse to-day fuller and quicker — 100; breathing not hurried; 
' feels unwell' to day ; tongue clean; some thirst; appetite good; bowels 
confined; skin dry; no change in the jaundice ; complains of tenderness 
at the point before mentioned. R. pil. hydrargr. gr. v. ter in die. Hiru- 
dines xii. P. D. 

u November7th — On the previous evening she became delirious, and this 
morning (7th), at the hour of visit, was quite comatose, and soon after died. 

" Post-mortem. — The brain and abdominal viscera were the only parts 
examined. The Jiver was not by any means enlarged, and a section of 
it disclosed no excess of blood. It was of a light brown colour, tinged 
with yellow, as if from a superabundance of the colouring matter of the 
bile. The gall-bladder was distended, and on being opened was found 
completely filled by a dark green mass of a tenacious viscid nature, appa- 
rently lymph. This substance was of the same pyriform shape as the gall- 
bladder, and terminated by its narrow extremity at the commencement of 
the gall-duct. On its removal, the lining membrane of the gall-bladder 
presented a bright scarlet colour and villous appearance, and the natural 
and beautiful 'honeycomb' arrangement of the mucous membrane was com- 
pletely effaced. There was no softening or ulceration of the membrane, 
nor was the colour different in any part. It resembled very much the ap- 
pearance of the mucous membrane in acute laryngitis. The walls of the 
gall-bladder were much thickened. There was no obstruction of the ductus 
choledochus, the cystic or hepatic ducts, and their lining membrane was 
quite free from any unusual vascularity; the duodenum and stomach were 
stained with the colouring matter of the bile, but in other respects were 
healthy; no gall-stones or other obstruction; the kidneys were natural. 

" Cranium. — The dura mater was stained of a yellow colour; there was 
no thickening or opacity of this membrane ; the arachnoid and pia mater 
were quite healthy ; the substance of the brain was firm and free from any 
unusual vascularity; no effusion of lymph in any part; the ventricles were 
not distended with fluid beyond what is normal, but the fluid, though in 
small quantity, was of a yellow colour, and the surface of the different 
parts contained in each ventricle was also of a light yellow colour; the 
nerves and all other parts of the organ were free from this staining. 

Case 5. — It may not be deemed superfluous to mention here the details 



INFLAMMATION — CAPILLARY CIRCULATION. 399 

of a case which was lately under the care of my esteemed colleague, par- 
ticularly as it required some skill to distinguish the features which it pre- 
sented from the ordinary and so frequently fatal combination we have just 
spoken of. An old woman was admitted, in September, 1842, into the 
Meath Hospital, labouring under jaundice, purpura haemorrhagica, and 
palpitations of the heart. Her habits were very intemperate, and shortly 
before admission she had been indulging largely: and when first seen 
by Dr. Stokes, she presented, in addition to the symptoms alieady enu- 
merated, many of the features of delirium tremens. She was exceedingly 
feeble, and her legs were anasarcous. After being under treatment for 
some time she began to improve ; when one night she was attacked with 
violent delirium, convulsions, and imperfect paralysis of the right side, 
she lost the power of speech and the mouth was drawn frightfully to the 
left side. The face presented almost all the phenomena which attend 
Bell's paralysis of the portio dura, but the head was cool, she complained of 
no uneasiness in this region ; the eyes were quite natural, and no increase 
in the strength of the pulsation of the carotid or temporal arteries could be 
detected. She lay sobbing and frequently sighing, and appeared extremely 
anxious to excite the sympathy of the spectators. These circumstances 
induced Dr. Stokes to make a most careful examination of the patient ; 
and having premised to the class that the case differed in many particulars 
from the ordinary combination, and that should it appear that there was 
really a connection between the jaundice and the supervention of the 
cerebral symptoms, the prognosis ought to be most unfavourable. He 
ascertained after some time, from the nurse and the other patients, that 
this woman, though fifty years old, was extremely hysterical, and had 
had, during her sojourn in the hospital, many attacks somewhat similar, 
though much more mild ; and by a further reference to her husband, it 
was discovered that she had been subject to these hysterical attacks for 
the last 30 years, and that she had frequently been affected with con- 
vulsions, raving, and even temporary paralysis, for years before the 
occurrence of jaundice. 

The nature of the case was then quite evident, and the patient was 
saved the risk which might have attended the employment of remedies 
the supposed complication would have indicated. It may, with truth, be 
said, that this was a very unusual combination ; but it shows, in my 
opinion, the necessity of patiently investigating, and carefully scrutinizing 
the characters of any rare, or hitherto unnoticed symptom, or combination 
of symptoms, in any particular case, for who might not have mistaken the 
cerebral symptoms in the example before us for the common complication 
which occurs in jaundice ? 



LECTURE XXXV. 



ON INFLAMMATION AND THE MOTOR POWERS, WHICH CAUSE AND REGU- 
LATE THE CIRCULATION. 

Gentlemen, — The general laws which govern inflammatory action, and 
the relation which the vascular system bears to that process, constitute a 



400 CLINICAL MEDICINE. 

most important subject, which has engaged the attention of the ablest 
pathologists and practitioners in this country for the last half century. 
Since the date of the great John Hunter's celebrated work, which gave 
the first impulse to this investigation, many British and Continental 
w r riters have applied their talents to the illustration of the changes the 
vascular system undergoes during the progress of inflammation. Thompson, 
Hastings, W. Philip, James, Burns, and Marshall Hall, have performed 
numerous and interesting experiments, which throw light on its pheno- 
mena ; and we have gained much by the assiduity and research they 
have displayed, in endeavouring to illustrate a matter of such acknow- 
ledged difficulty. Still, these authors appear to have adopted some 
erroneous views, and to have misunderstood or overlooked some points 
of peculiar importance. I shall first direct your attention to the opi- 
nions of Dr. Marshall Hall, as explained in his lectures, now in course 
of publication in the Lancet. Dr. Hall, possessing extensive acquire- 
ments and high professional reputation, has cultivated the sciences of 
physiology and pathology with distinguished zeal, and made numerous 
experiments and microscopical observations, tending to illustrate the sub- 
ject of inflammation ; his opinions are, therefore, entitled to serious con- 
sideration. 

In the last volume of the Lancet* page 76, Dr. Hall, speaking of the 
inflammatory process, observes — *' I conclude that each cause of inflam- 
mation first induces such a physical effect upon the internal surface of the 
capillaries, as leads to the adherence of the globules of blood to it, and 
to their ultimate stagnation. This stagnation augments as the inflamma- 
tion increases, and becomes more diffused, and seems to constitute the 
essential character of the disease." Here you perceive that the first step 
is the adherence of the globules of the blood to the internal surface of the 
capillaries, the consequence of which is, that the calibre of these vessels 
is considerably diminished, so that they become obstructed, and cause a 
stagnation of the blood, which Dr. Hall looks upon as the essential 
character of inflammation. 

Further on he says — " I have never been able to detect any action in 
the capillaries themselves. It is, probably, by the partial obstruction to 
the circulation in the capillaries, that the minute arteries become en- 
larged." Now observe, according to this mode of explanation, the cir- 
culation being obstructed in the capillaries, in consequence of the adhe- 
rence of the globules of blood to their sides, the arteries which supply 
them are propelling blood into obstructed vessels, and consequently be- 
come enlarged or dilated — and why? Dr. Hall says, " according to the 
well-known law, that muscular organs augment, with obstacles to their 
functions." Here I may, in the first place, observe, that Dr. Hall is not 
warranted in looking upon the minute arteries as muscular organs ; but 
waiving this point, how can the law alluded to explain the supposed increase 
in the capacity of the minute arteries? It might, indeed, explain the 
increase of thickness in their parietes ; but is it not plain, that this very 
addition to the thickness of the arterial walls, so far from increasing, must 
diminish their calibre ? 

Again, he observes — u It is probably by the fact of stagnation that 
inflammation differs from blushing, eruptions, &c." Here, you perceive, 

* This and the following lecture were delivered in the last week of November, 1837. It 
will be seen that I have since added many references to books published in 1838. 



INFLAMMATION — CAPILLARY CIRCULATION. 401 

he introduces the qualifying term, " probably." He continues — " It is 
generally asserted, that there is a series of vessels which only circulate 
the serum of the blood, and exclude the globules. This I believe to be 
mere hypothesis. Vessels which only admit of single globules will 
appear colourless. In inflammation, the minute arteries which only admit 
single globules at a time, enlarge, and admit a greater number, and then 
the red colour becomes visible." He goes on then to say — "This en- 
largement of the blood-vessels is not confined to the minute arteries, for 
the larger vessels in the immediate vicinity of the inflamed part also be- 
come enlarged. * * * * This is owing to the obstruction of the 
true capillaries." And he illustrates this by instancing the application of 
a ligature to an arterial trunk, the consequence of which is, that the col- 
lateral arteries of the part become increased in size, in consequence of 
the obstruction. We shall see afterwards, how little this admits of being 
proved. He says — u It is not known how far this enlarged state of the 
arteries extends from the seat of the inflammation ; but, in the case of an 
inflamed finger, the pulse at the wrist of the corresponding arm beats 
more strongly than it does on the opposite one." 

Such are Dr. Marshall Hall's views of the causes of inflammation, and 
the part which the capillaries and minute arterial vessels play in that in- 
teresting process. You perceive, by the brief outline which I have given, 
that he attributes all the phenomena to adherence of the blood-globules 
to the sides of the capillaries, the consequent obstruction of these vessels, 
and the enlargement of the minute arteries to which that obstruction gives 
rise. In this view of the case the vessels are regarded as passive, and 
are distended on purely mechanical principles ; in fact, their enlargement 
is a mere dilatation. 

Notwithstanding the respect I entertain for the learning, ability, and 
industry of Dr. Marshall Hall, I must say that I look upon his views as 
purely hypothetical, and am convinced, that he has arrived at unsound 
conclusions with respect to the nature of inflammation. I shall not, how- 
ever, take up your time by going over his positions seriatim, and showing 
their untenable character ; but shall proceed at once to lay before you the 
opinions to which observation and reflection have led me, and which 
have been taught for many years in my lectures on the Institutes of Medi- 
cine. I shall not, like Dr. Marshall Hall, attempt to explain the nature 
of inflammation, or determine its proximate cause, but shall content my- 
self with endeavouring to arrange its phenomena, and point out their 
order, and the share which the capillaries have in the inflammatory pro- 
cess. Before entering on this subject, it may be necessary to premise a 
few observations on the circulation in general. 

The human body is composed of various parts, differing in their ulti- 
mate structure, chemical composition, and vital functions. There is a 
very remarkable difference between muscle and cellular tissue, and be- 
tween the latter and nervous tissue. If we examine these parts more 
closely, we find them differing, not only in their structural arrangements, 
but also in the ingredients or materials of w T hich they are composed. In 
muscle we find a large quantity of fibrin and colouring matter ; in carti- 
lage, fibrous membrane, and tendinous substance, we find more or less of 
the fibrous structure of muscle, but we do not meet With, fibrin, and there 
is not the slightest trace of colouring matter. The same blood furnishes 
materials for the growth and nutrition of all, and conveys the nutrient 
27 



402 CLINICAL MEDICINE. 

particles to red and white tissues alike ; but the white parts require not 
red blood, and consequently receive none. Blood is a compound fluid, 
which contains, as it were, the raw material of all the tissues in a fluid 
state ; it is, in fact, flesh in a state of fluidity, and destined to combine 
with and support the solid portions of the frame. It is conveyed by the 
arteries all over the body, supplying each tissue with its appropriate ma- 
terials, and contributing to its growth, sustentation and repair, in the 
amplest, and yet in the most economical manner. It does not enter the 
tissue of every organ in that state which has been termed arterial, and in 
which it appears as a fluid of a bright red colour. This is an error of 
which nature is never guilty. It would be absurd if all parts of the blood 
were carried to all the different tissues indiscriminately ; and it would, 
moreover, be a great waste of vital and mechanical power. The chief 
bulk of the blood is made up of a transparent fluid or lymph, holding in 
solution various salts, besides albumen and fibrin. The red globules are 
immersed, but not dissolved, in this fluid ; and it appears from the ob- 
servations of Mayer, that in the minute vessels the red globules occupy 
the central part, surrounded by the transparent fluid. The colouring glo- 
bules are necessary for the nutrition of muscular, mucous, and some other 
tissues ; and are carried by the minute vessels wherever they are required. 
Every part of the blood is required in a muscle ; fibrin and colouring mat- 
ter for its essential fibre ; albumen, fatty matter, &c, for its cellular and 
adipose membrane. The white tissues, as I have already observed, re- 
ceive no red blood, because they require none — this is quite certain. 
Serous membrane, for instance, contains neither fibrin nor colouring mat- 
ter ; at what point of the circulation does the separation of the albumen 
take place ? Is it an act of nutritive secretion which separates it from the 
whole mass of arterial blood, or are only the serous portions of the blood 
carried to the white tissues ? " Serous vessels," says Miiller, " that is, 
branches of the blood-vessels which are too minute to allow the passage 
of the red particles, and which are traversed, therefore, merely by the 
lymph of the blood, may possibly exist, but they have not been demon- 
strated. " 

It seems to me, however, that it is by no means necessary for blood- 
vessels to be too minute to allow the passage of red globules, in order to 
make these vessels the vehicles of lymph alone. The entrance of the 
globules into them will be determined by other circumstances than their 
size. Already, as the blood approaches the capillary system, the micro- 
scope detects a tendency to a separation between its lymph and colouring 
globules ; and no doubt their complete separation is effected by vital 
agencies, independent of mere calibre. Hence we may explain the 
fact, that no red blood seems to circulate in serous membranes during 
health ; but the moment inflammation sets in, the natural play of vital 
energies is deranged, and the red globules, finding their way into unwonted 
channels, vessels innumerable, before filled with a transparent lymph, 
and therefore not visible, start suddenly into view, in consequence of 
their now containing an opaque and coloured fluid. 

According to Hall, Miiller, and other physiologists, all minute vessels 
contain red particles, which, however, are believed to exert no influence 
on their colour, so long as these particles are only admitted singly, and 
not several at a time. But when inflammation comes on, according to 
Hall these vessels are enlarged in consequence of obstruction, and then 



INFLAMMATION — CAPILLARY CIRCULATION. 403 

admitting a greater proportion of red globules, become visible. Now, 
gentlemen, observe how suddenly, when the conjunctiva connected with 
the sclerotic is irritated, numerous vessels appear filled with red blood. 
Here is no time for the adhesion of globules to the internal surfaces of 
the vessels — no time for the gradual enlargement of vessels previously too 
small for the admission of the red globules ; no, the vessels existed there, 
but they contained no red globules; they admitted none, because their 
admission would have proved unnecessary or injurious. I do not deny 
the sudden enlargement of minute vessels ; on the contrary, I believe in 
it most firmly, and am persuaded that the minute and capillary arterial 
branches which admit in health only lymph, may suddenly expand and 
increase in size. I do not, for reasons hereafter to be detailed, consider 
this expansion as passive ; and I believe that the red globules made little or 
no part of the fluid previously circulating in these vessels. Indeed, it 
seems rather illogical to argue that, because red globules might be present 
without imparting a perceptible red colour to this fluid, that, therefore, 
they are present. When the contents of a vessel are to the eye colourless, 
the onus probandi lies with him who asserts the presence of red colouring 
matter ; and until that is proved in each particular case, the contained fluid 
must be regarded as colourless. 

As to the idea that lymph vessels could not exist unless their diameter 
was smaller than that of the red globules, it is too mechanical to deserve 
serious attention. The entrance of animal matters into, and their pro- 
pulsion along vessels, depend most assuredly on other conditions than 
mere size of particles. Indeed, Muller expressly says— " In the most 
minute capillaries which are not red, nor even yellow, but quite transparent, 
there is merely a single line of red particles, separated by unequal intervals, 
and from time to time no red -particles are seen in these colourless vessels ; 
but I have seen no canals through which red particles did not occasionally 
pass, and which, therefore, deserved the name of vasa serosa, and Wede- 
meyer, who says he has seen such vasa serosa himself, confesses that 
some of the red bodies traversed them from time to time. Here, then, 
we have my argument confirmed by observation, and the fact proved, 
that the entrance and passage of the red particles does not depend on the 
mere size of the vessels. 

If we take an accurate view of the general circulation, we shall find, 
then, that there is a great circulation of red fluid containing the raw ma- 
terial of all the tissues ; which fluid, in its integral state, is destined chiefly 
for the muscles of voluntary and involuntary motion, into every part of 
which red vessels penetrate, and from which red blood returns. In fact, 
red blood forms as it were, a separate circulation, sweeping by the white 
tissues, to which it merely detaches its uncoloured lymph, while the red 
blood enters the capillaries of the red tissues. When the minute arteries 
arrive at the parts where red blood is no longer necessary, they send off 
smaller vessels which contain only white blood, mixed with compara- 
tively few, if any red globules, while the branches which carry red blood 
proceed to join the corresponding veins. 

I dissent from the common notion that the circulation of the blood goes 
on very rapidly. It has been computed that the heart expels from two to 
four ounces at each stroke of the left ventricle ; and if we compute the 
quantity of blood in the body to be from twenty to thirty pounds, we 
shall be led to conclude that the whole mass of the blood passes through 



404 CLINICAL MEDICINE. 

the heart in a very short space of time. This, however, is only taking a 
partial view of the matter. It is true that there is a rapid central current 
of red blood which accomplishes its circle through the body in a very 
short time, but a large proportion of the juices of the body circulates 
very slowly through the tissues it supplies, being detained in the capillary 
system for a considerable period before it is returned to the general mass 
of the circulation. If you compare the relative circulations of different 
classes of animals, you will find that they differ considerably in the com- 
position of their blood, as well as the rate at which it travels through the 
system. Some animals have only white blood and a capillary circulation, 
without any distinct arteries or veins. Others possess vessels correspond- 
ing to arteries and veins, but still no distinct organ like the heart. 
Finally, we arrive at a higher class, which have not only distinct arteries 
and veins, but also a heart. In each of these classes the circulation 
differs not only in the properties of the circulated fluid, but also in 
the velocity w T ith which it travels. It is much slower, much more slug- 
gish, in the lower than in the upper classes of animals. In the same way, 
blood does not circulate so rapidly in tissues of a low degree of organiza- 
tion (as bone, cellular and fibrous membrane), as in the red parts of the 
body. It is, therefore, not unreasonable to suppose that bone lives at one 
rate, fibre at another, muscle at another, and nervous matter differently 
from all. These views are of importance when brought to bear on the 
subject of inflammation, and tend to explain the slow progress it makes 
in certain tissues. 

You must have perceived that, from the very beginning, I have rejected 
the idea that the blood is propelled through the system by the vis a tergo 
alone. If that were the case, the current, though diminishing in velocity 
as it receded from the heart, would be equable in vessels of the same size 
throughout the whole system. But, in my opinion, the current of circu- 
lation has many different rates, which depend not on the vis & tergo alone, 
or the distance from the heart and size of the vessels,* but on the vital 
energy of the vessels themselves. Hear what Miiller says on this subject : 
— " Wedemeyer's description of the course of the blood in the anasto- 
mosing capillaries agrees perfectly with what I have observed. Some- 
times, he says, the red particles flow rapidly from one current into an- 
other, as if by attraction. In other cases the current which they join is 
very rapid, but they are arrested, as it were, in the collateral current, and 
only from time to time find means of entering. Sometimes a red particle 
is even thrown back out of the rapid current into a weaker stream, and 
is then again repelled. I have also remarked that the same anastomosing 
branch between two currents sometimes receives the blood in one direc- 
tion, and sometimes in the other, and that variations of pressure and posi- 
tion, and motions of the animal, are always the causes of these changes." 

Such is Miiller's testimony concerning the circulation in the capillaries, 
and it bears me out in the assertion, that a very great portion of the blood 
(using that word in its most comprehensive sense, and meaning thereby 
nutritive fluid) is comparatively stagnant in the capillary system ; but I 
must confess that I felt much astonishment at Miiller's assertion, that " all 
these variations in the capillary currents are, just as in currents of water 
in irrigated land, merely the result of mechanical causes." 

* The blood's velocity in its progress from the heart is diminished chiefly by two physical 
causes, viz., increase of friction, and the increasing capacity (considered as a whole) of the 
vessels which contain it. 



INFLAMMATION — CAPILLARY CIRCULATION. 405 

Having made these preliminary observations, we are now better pre- 
pared to speak of the forces by means of which the circulation of blood is 
accomplished. Most authors, and with them Muller, have stated that the 
motion of the blood in the capillaries is wholly dependent on the heart's 
action. Now these vessels are mere simple membranous tubes, and there 
is no doubt that their membranous parietes must exert a strong power of 
endosmosis and exosmosis, as shown by Dr. Rogers, in the American 
Journal of Medical Science. This power must necessarily have a great 
influence on the motions of the blood contained in the capillaries, causing 
a mutual interchange of contents between vessels in contact with each 
other, and between the vessels and surrounding parenchyma of the organs. 
Again, it has been proved by Dr. Draper, in the same journal, that in 
capillary tubes and organic pores a motion of the contents must result 
when the contained fluid possesses certain physical properties, from its 
mere contact with the internal surface of vessels so minute. 

Here, then, are two sources of motive power, quite independent of the 
heart's action, and which must necessarily influence, in a most important 
manner, the capillary circulation ; but this is not all, for there resides in 
the small vessels connected with the capillaries, whether minute arteries 
or minute veins, a vital sensibility which enables them, by suddenly or 
gradually changing their calibre, to increase or diminish the quantity of 
fluid in any particular organ or tissue. 

Facts in abundance may be brought forward in proof of this assertion. 
When a fatty or a fleshy tumour arises on any part of the body, we have 
new vessels, as it were, created ; and there is no reason to attribute their 
formation to any thing like a dilating vis a tergo. But the formation of 
the vascular system in the foetus affords the strongest proofs. Here the 
smaller and more minute parts are formed first, the development com- 
mencing with the capillaries, and extending to the minute arteries and 
veins, and then to the larger trunks ; until, at last, the heart is super- 
added, at first of an elementary, afterwards of a complicated structure. 
The best account of the development of the vascular system in the foetus, 
is contained in Von Baer's work, published in 1837, in Konigsberg.* 
He says (Part II. p. 126), that there is no doubt that the blood is formed 
before the vessels. The formation of blood goes on in every part of the 
body, and, when formed, it is put in motion by the agency of some un- 
known cause which impels it in the proper direction, until it at length 
reaches the central formation of blood, around which is developed a 
tubular canal, afterwards to be further modified and changed into the 
heart. In truth, the first motions of the blood are towards the heart, and 
consequently the first vessels formed , are the veins ; a fact in itself sufficient 
to disprove the hypothesis that this motive power which presides over the 
circulation resides exclusively in the ventricles of the heart. What do 
we find occurring in the case of pseudo-membranes resulting from pleu- 
ritic inflammation ? Exactly what takes place in the development of the 
foetus. A large quantity of lymph is effused, which at first has no vascular 
connection whatever with the parietes of the chest. After some time, 
however, the effused lymph becomes organised, and vessels begin to form 
in its substance ; these extend gradually, and join the vessels of the tissue 
with which the lymph lies in contact. Of this formation of vessels in 
effused lymph there can be no doubt ; I have often examined it with ad- 
* Uber Entwickelungsgeschichte der Thiere, &c-, &c. 



406 CLINICAL MEDICINE. 

miration, and it is likewise attested by Andral. When a mass of lymph, 
effused into the pleural cavity, is about to organise itself, and become 
vascular, a vast number of red points make their appearance throughout 
the mass, and are connected with very minute streaks, having a vascular 
distribution. In this lymph, then, red blood is manufactured, as in the 
foetal body at an early period of development, and vessels are formed ; 
and sanguineous circulation, no doubt, exists. 

These facts, I say, bear strongly on the question before us, proving 
beyond a doubt that the vital properties of living matter are capable of 
forming vessels, and of rapidly increasing their size when formed. To 
account for the sudden increase in the size of vessels belonging to an 
inflamed part, we must look to this fact, and not rely solely on increased 
visa tergo, aided by obstruction. 

Now the whole of Dr. Marshall Hall's explanation depends on these 
two causes — vis a tergo, and obstruction. But I say that vessels may be 
formed, multiplied, and enlarged, independently of these causes, and in 
consequence of an altered vital action of the parts in which the process 
occurs. Let me refer to the case of the impregnated uterus. In the 
un impregnated state, the womb is a small organ, with vessels and 
nerves so small as scarcely to admit of being satisfactorily traced. What 
takes place after conception ? It has now new and important functions 
to perform, and it becomes proportionally increased in magnitude and 
vital activity ; its arteries and veins become elongated and enlarged ; its 
walls become thickened, and its nerves increased in size. And yet we 
are told that this increase in the size of its vessels depends on obstruction. 
Where does the obstruction exist? What proof have we that there is 
any increased vis a tergo ? Will any of these principles account for the 
augmented size of its nerves ? Tiedemann has proved beyond contra- 
diction that the nervous matter of the womb is augmented to a very 
remarkable degree, during the impregnated state, and that minute nervous 
filaments, scarcely discoverable with the aid of a microscope, eclarge into 
bands visible to the naked eye. The same thing occurs with respect 
to the minute arteries and veins ; from being but barely perceptible, they 
become large tortuous vessels carrying an abundant supply of blood, and 
performing their functions with extraordinary activity. I do not pretend 
to offer any explanation of these facts ; I merely place them before you, 
and show you the analogy which exists between the vascular and nervous 
development. 

The vessels increase in size and capacity, so do the nerves ; and the 
augmented size and capacity of both depend on the same unknown cause. 
The nerves are developed in the same order as the vessels, and, like the 
latter, they increase from the circumference to the centre. Nay, I am 
persuaded, that, did our means of investigating the matter possess the 
same advantages as those we enjoy in the examination of the vessels, 
w T e should find that, in inflamed parts, the nervous matter increases, 
in many cases, as rapidly, and to as considerable an extent, as the 
vascular. 

So far, gentlemen, I have endeavoured to lay before you proofs of the 
independence of the capillary circulation, a fact which I have long since 
brought forward in my public lectures, and of which I have written 
somewhat in detail, in my review of Dr. Joerg's work on Atelectasis of 
New-born Infants. These views, I am happy to state, have been further 



INFLAMMATION — CAPILLARY CIRCULATION. 407 

confirmed by Dr. Houston, in a paper published in the 29th number of 
the Dublin Journal.* In that paper, which I recommend to the attentive 
perusal of every student, Dr. Houston gives an account of an extraordinary 
case of twins born of a healthy young woman, between the seventh and 
eighth month of her pregnancy. One of the children was, to all outward 
appearance, perfect in every particular, and of the full growth of its age ; 
the other, a female, and the subject of Dr. Houston's communication, 
was a monster, of somewhat smaller size than its companion. Both 
were alive at the time of delivery, but died almost immediately after. 
There was a separate cord, and a separate set of membranes, for each 
foetus. The abnormal one had neither brain, heart, lungs, or liver ; the 
kidneys were of enormous size, nearly filling the abdomen, and extending 
to the apex of the cavity formed by the ribs. 

The umbilical vein, after quitting the cord, descended between the 
abdominal muscles and peritoneum as far as Poupart's ligament, and there 
opened into the external iliac vein, which became enlarged in size at this 
point. From this vein all the veins of the body were derived ; large 
branches passed to the pelvis, thighs, and kidneys, and smaller ones to 
the intercostal spaces, and the tumour which constituted the head. These 
veins were devoid of valves, and terminated in the capillaries. From the 
latter, the arteries began by fine roots, and gradually coalescing, united 
into a sort of aorta on the fore-part of the spine, which descending, divided 
into the iliac and hypogastric arteries in the usual way. No communica- 
tion existed between the arteries and veins, except at their capillary 
terminations. 

Such is the history of this very remarkable case, as given by Dr. 
Houston. I have not time at present to enter into his arguments ; but I 
think he has satisfactorily proved, that in this instance, the circulation 
was carried on without the aid of the heart of the other twin (as supposed 
by Sir Astley Cooper), or of the heart of the mother, and that it depended 
solely on the vital energy of the capillary and other vessels. 

Another case of a monster without a heart, is related in the American 
Journal of Medical Sciences, for February, 1838, by Dr. Jackson, of 
Boston. This was likewise a twin ; and there can be but little doubt that 
its circulation was quite independent of any assistance derived from the 
heart of its fellow. 

I have already spoken of the dilatation of the arteries and veins of 
inflamed parts, as being produced by something very different from mere 
distension ; and that it is not of a passive but an active nature. That the 
larger vessels actively dilate can scarcely be doubted by any one who 
has observed the state of the temporal arteries in phrenitis, or apoplexy ; 
that the veins have a similar power, may be observed on plunging the 
hands or feet into a hot medium, whether moist or dry. Blisters applied 
to the skin produce for the time increased size of the cutaneous veins ; 
and sores on the leg may, when considerable and long-continued, give 
rise to a varicose state of the veins. When a grain of sand falls into the 
eye, how sudden is the redness — how numerous the vessels which now 
appear gorged with blood ! This .change takes place in a few seconds, 
and, in my opinion, can be much more satisfactorily accounted for, by- 
supposing that the capillaries and smaller vessels enjoy a wide range of 

* A full account of this foetus is given in a note to my lectures on Fever at the beginning 
of this work. 



408 CLINICAL MEDICINE. 

size, if I may use the expression, and are capable of enlarging or dimi- 
nishing their calibre, according to the exigencies of the case and the state 
of the circulation. That the large arteries and veins do so, is acknow- 
ledged by all, and is proved by arterial trunks contracting on their con- 
tents so as to maintain their proper tension ; no matter how much blood 
is drawn from an animal. The larger veins are capable of a like contrac- 
tion and expansion : can similar properties be denied to the smaller arte- 
ries, possessing, as they do, an elastic coat proportionably thicker ? The 
vascular phenomenon attending a blush ought to have taught physiolo- 
gists how rapidly, how instantaneously, blood may be drawn to a particular 
part, and may again desert it ; and that, under circumstances where the 
vis ti tergo could not determine a flow of blood to the part in question, 
more than to any other in the body. Do we need microscope examina- 
tions on the capillaries of recently killed animals to instruct us, when such 
phenomena offer themselves, as it were, for the very purpose of illustra- 
tion ? When the child breathes for the first time, the air admitted into the 
lungs gives new energy to their capillaries, and at once the great current 
of blood flows through the pulmonary arteries, deserting the ductus arte- 
riosus. In a seven months' child the latter passage is still very large ; 
and yet, when the child breathes, its being open effects very little, if any 
thing, towards diminishing the flow of blood into the pulmonary arteries. 

Here, again, we observe how arteries grow independently of mere 
pressure from within ; for the pulmonary arteries and pulmonary veins 
are enlarging themselves long, long before they are called on to be chan- 
nels for a quantity of blood at all proportioned to their calibres. John 
Hunter observed the enlargement of the arteries of an inflamed part, and 
his observations, and those of others, have brought to light a periodical 
and remarkable increase in the size of the vessels destined to promote the 
growth of the stag's horns. Are we, in this case, to explain that enlarge- 
ment by obstruction, or by the vis a tergo ? It is impossible to do so ; and 
we must, then, look to the vessels of the part itself for a solution of the 
question. In such instances, as in the case of the pregnant uterus, these 
vessels are endowed with this power of growth and enlargement, quite 
independently of the general vascular system, or the action of its centre — 
the heart. 

I am the more anxious to impress on you this view of the subject, as 
the hypothesis of obstruction has been adopted by many late writers, as 
explanatory of the local changes of circulation attending inflammation. 
Thus Dr. Williams, in his admirable lectures published in the Medical 
Gazette (No. 528), says, "We cannot, in the present state of pathological 
knowledge, doubt that the circulation through the inflamed vessels is, to 
a certain degree, obstructed ; whilst, either as a consequence of this, or 
from some co-operating influence, the vessels leading to the part become 
dilated, and being thus more open than others to the pulse-wave of the 
heart, they become the seat of that throbbing hard pulse that has been 
mistaken for increased action of the vessels themselves." 

Now, gentlemen, you observe here that Dr. Williams expresses himself 
doubtfully about the dilatation of the vessels being caused by obstruction, 
and he even speaks of some co-operating influence. We shall, therefore, 
content ourselves with having recited his opinion on this point. I must 
observe, however, that the dilatation of the vessels, however caused, can, 
on no principle, account for their becoming the seat of throbbing, and a 



INFLAMMATION — CAPILLARY CIRCULATION. 409 

hard pulse : their being more open than others to the pulse-wave from the 
heart, could, at the utmost, only place them in the situation of other arte- 
ries naturally of the size they have now attained to ; but we do not find 
that such arteries throb, or have a hard pulse. Arteries do not throb, or 
become the seat of a hard pulse, in proportion to their size. That is not 
the fact; and, consequently, Dr. Williams's explanation cannot be ad- 
mitted. 

Dr. Weatherhead, who has arrived at very nearly the same view of the 
subject with myself, says, " The first effect of an excitant, or irritant, ap- 
plied to any part of the body, is to attract the blood to the seat of irrita- 
tion, and to quicken its current in the capillaries." So far we perfectly 
agree. Here Dr. Weatherhead estimates the vital energy of the vessels 
of the part at its true value, and does not call in the aid of an increased 
vis a tergo to account for an augmented determination of blood to any 
particular locality; but to what follows I cannot accede. "If these 
effects be kept up beyond a certain period, or carried beyond a certain 
degree, the excitation continues to attract as much blood as before, while 
the power of the capillaries to forward it diminishes, by the exhaustion 
ensuing from their prolonged over-action." There seems but a weak 
analogy in support of the assertion, that increased vascular action must 
necessarily produce vascular exhaustion. 

It may be objected to my view, that dilatation of an active nature can- 
not be conceded to the capillaries, whose coats are quite thin and mem- 
branous ; but when the objects are so minute, it is quite impossible to 
determine the physical or vital powers of tissues ; and we should recollect 
that what is deficient in degree may, in the case of the capillaries, be 
made up by their number, which is immense in every part of the body. 
Still, so far as our observations do go, they seem to establish the property 
in question. Muller, whose opinion upon all physiological questions is 
of the greatest weight, has adopted on this subject an hypothesis which 
appears to me to be quite untenable. It is observable, that the first of the 
following paragraphs, which I quote from his work, proves, that w T hen 
writing it, he felt conscious that the remarkable phenomena of vital tur- 
gescence are totally irreconcileable with the theory, which denies any per- 
manent circulating power but that of the heart, and which asserts that 
" the motion of the blood in the capillaries is wholly dependent on the 
heart's action !" Let us hear what he says concerning vital targescencc 
of the blood-vessels (p. 224) : — " Although it be denied that the circulation 
is in any way aided by an attraction between the blood and the capilla- 
ries, the existence of such an attraction or affinity may, nevertheless, be 
admitted in the instance of the ' turgescence, turgor vitalis, or orgasm,' 
which is observed to take place in certain parts of the body, independent 
of the action of the heart. This condition of turgescence in animals is 
analogous to phenomena which are so evident in plants, such as the afflux 
of sap to the fruit-bud, which contains the impregnated ovum. 

" The mutual vital action, or affinity between the blood and the tissues of 
the body, which is an essential part of the process of nutrition, is, under 
many circumstances, greatly increased ; and an accumulation of blood in 
the dilated vessels of the organ is the result. It is seen, for example, in 
the genitals, during the state of sexual desire, in the uterus during preg- 
nancy, in the stomach during digestion, and in the processes of the cra- 
nial bones on which the stag's antlers afterwards rest, during the repro- 



410 CLINICAL MEDICINE. 

duction of these parts. The local accumulation of blood, with the dila- 
tation of old, and the formation of new vessels, is, however, seen most 
frequently in the embryo, in which new organs are developed in succes- 
sion by a process of this kind ; while, on the other hand, other organs, 
such as the branchiae of the salamander and frog, and the tail of the latter 
animal, become atrophied and perish as soon as the vital affinity which 
existed between the blood and their tissues ceases to be exerted. 

" The phenomena of turgescence have been supposed to be dependent 
on an increased action or contraction in the arteries. But arteries present 
no periodic contractions of muscular nature ; and a persistent contraction 
of the arteries, unless it were progressive (vermicular, as it were, or aided 
by valves arranged in a determinate direction), would be quite inade- 
quate to produce a state of turgescence of any part. 

" To explain the state of orgasm of the uterus during pregnancy, and 
of the bony processes which bear the antlers of the stag, we must presup- 
pose the existence of an increased affinity between the blood and the tis- 
sue of the organ. This condition may be excited very suddenly, as is 
seen in the instantaneous injection of the cheeks with blood, in the act of 
blushing, and of the whole head, under the influence of violent passions ; 
in both of which instances, the local phenomena are evidently induced by 
nervous influence. The active congestion of certain organs — of the brain, 
for example — while they are in a state of excitement, is a similar pheno- 
menon. 

" If the organ which is susceptible of the increased affinity between the 
blood and the tissue is, at the same time, capable of considerable disten- 
sion, tumefaction and erection take place." 

It will, I believe, be readily acknowledged, that Muller's explanation 
is, after all, a mere hypothesis. Is this affinity between the blood and the 
tissues of the body, chemical? or is it a mutual vital action? If the latter, 
then the vessels, they being the only tissues in contact with the blood, are 
active, contrary to his previous hypothesis. As to the chemical explana- 
tion of a blush, it surely does not merit examination. 

The facts referred to by Miiller in the above passage, all tend to corro- 
borate the view I have adopted, and show that local changes of nutrition, 
vascularity, and circulation, may be quite independent of the heart's 
action. 

We must next turn our attention to the increase in size of some of the 
larger arteries. 

"Apply a ligature," says Dr. Hall, "to the principal artery of a limb, 
the circulation is then carried on by the collateral branches, which become 
enlarged for this very purpose, and in consequence of the obstruction." 

Now let us study the phenomena a little more accurately, and we shall 
soon see how erroneous is this explanation. 

In the first place, what are the physical results produced by tying one of 
the large arteries of a limb? The vis h tergo, or propelling power of the 
heart, continues just as before ; the quantity of fluid or blood within the 
whole system of arterial tubes is unchanged, while the forces to be over- 
come by the circulating power remain also the same. In fact, all the 
general physical conditions are unaltered after the ligature has been ap- 
plied, except that a portion of the blood can no longer enter the tied ar- 
tery. Let us now investigate what effects this non-entrance of a certain 
portion of the blood into its accustomed channel is likely to produce on 



INFLAMMATION — CAPILLARY CIRCULATION. 411 

the rest of the arterial system. When the principal artery of a limb is tied, 
the blood circulating in the remaining arteries of the body, and the other 
arteries of that limb, is pressed more strongly against the arterial parietes. 
But as the distending force resulting from this increased pressure is not 
confined to any particular artery of the body, but affects all, more or less, 
it is obvious that a power so extensively distributed and subdivided can 
exert but little distending influence on any individual artery, or, in other 
words, can tend but little to dilate any of the arterial tubes. Now it is 
obvious, from the laws of hydrostatics, that this increased pressure will be 
more exerted in proportion on the main collateral arteries of the limb, than 
on the smaller; it will, in truth, be scarcely sensible in the latter, and yet 
these are the very arteries which enlarge first after the operation for aneu- 
rism. The increase in the size of the arteries commences, not w T here it 
ought to commence, if it depended merely on dilatation from increased 
pressure, viz. in the larger arteries, and in the collateral branches close to 
the ligature, but it commences in the smaller and more distant arterial ra- 
mifications. In addition to the fact that a proportionally less pressure is 
thrown on the smaller arteries, we shall recollect that the latter have pa- 
rietes much thicker in proportion to their calibre, than the larger branches. 
This is another material objection to Dr. Hall's explanation of their in- 
crease in size. What are the phenomena observed after applying a liga- 
ture to an artery of large size, where a sufficient collateral circulation may 
be applied? First, the sudden diminution of circulation in the parts below 
the ligature gives rise to coldness and paleness of the limb; but in a few 
hours the circulation gradually returns, the thermometrical temperature of 
the limb rises, and the activity of the capillary system is greater than in 
the natural condition of the limb. This excitement continues for some 
time, and then diminishes to the ordinary standard of health. In eight, 
twelve, or twenty-four hours after the application of a ligature to the main 
artery of a limb, we find the skin of the parts below the ligature pale and 
cool, but in a few hours afterwards its temperature rises, and it exhibits 
an evidently increased arterial action. Now it is difficult to conceive that 
the main collateral branches have been dilated in so short a space of time. 
The mode in which the phenomena witnessed in this instance are best 
explained, seems to me to be the following. When a large portion of the 
blood destined for the supply of a limb is cut off, all the tissues of a part 
so deprived receive a shock: the muscles, nerves, capillary vessels — in 
fact, the vital functions of the w r hole — are more or less affected. After 
some time, how T ever, the vital depression is followed by reaction, and this 
commences in the smaller arteries and capillary system, its commencement 
being marked by uneasy sensations, increase of temperature, and arterial 
throbbing. The initiative of the restoration of the circulation belongs to 
the extreme vessels, which take on an increased action, and this is gradu- 
ally extended to larger arteries. These gradually augment in power, be- 
come enlarged and distended, and at length the circulation of the affected 
limb is restored to a state of efficacy, equal, if not identical with its pris- 
tine condition. Now, you are told that the increased activity of the capil- 
lary vessels, in this instance, is referable to the vis a tergo operating through 
the anastomosing branches. This is a false assumption. In the first place, 
the influence of the heart's action, when the blood passes through small 
anastomosing branches, and by circuitous courses, must be less powerful 
than- before the operation, when the main channels remained pervious. 



412 CLINICAL MEDICINE. 

The vis ti tergo is therefore lessened, and yet the capillary distension is 
greater than before the operation, or in the sound limb. In the next place, 
this argument is of more force, when it is considered that the enlargement 
commences in the smaller, and gradually extends to the larger vessels ; 
and also, that in some cases the branches from the main artery through 
which the blood must pass, do not become perceptibly enlarged. Thus 
Mr. Hodgson, in the work on diseases of arteries, says — u The dilatation 
takes place principally in minute ramifications. The trunks, and the 
mouths of the vessels going off above the place of obstruction in the main 
artery, in several preparations, did not appear larger than in their natural 
state, and in a few instances only a slight dilatation was perceptible." 
From these facts it is obvious that the vessels least under the influence of 
the heart are the most dilated. But the most decisive proof is the return 
of the capillaries and minute arteries to their ordinary size, at the time 
when, the larger branches being dilated, the vis a tergo should be more 
operative. Hence it would appear that the power of distension resides in 
the arteries themselves, the irritation commencing in the capillaries, and 
being sympathetically propagated to the larger vessels. This is further con- 
firmed by the fact, that, if an inflamed part, or a vascular tumour, be supplied 
by several arteries, and one of them be divided, the others will enlarge. 

It is scarcely necessary for me to direct your attention here to the phe- 
nomena which occur in the erectile tissues, as the corpora cavernosa, &c. 
It cannot surely be maintained that the sudden increase in the afflux of 
blood to these parts is owing to any vis a tergo, or momentary augmentation 
of the propelling power of the heart. No ; tissues of this kind enjoy the 
power of attracting to themselves an increased quantity of blood, in virtue 
of the vital power resident in them, and not from any peculiar exertion of 
extraneousforces. In fact, the capillary vessels enjoy the property of actively 
dilating, and drawing the blood into them, and this appears to be one of the 
principal causes of the circulation. Of this there is abundant proof. It 
has been observed in vivisections, that after the heart has ceased to act, the 
capillary vessels remain distended, and appear to carry on their functions as 
long as any blood is supplied to them from the arteries. It has been also 
remarked, that the larger arterial branches become first empty, then the 
smaller, and finally the capillaries. Dr. Philip states, that he has observed 
the circulation of the mesentery to continue for several minutes after the 
heart had been excised. This is the true explanation of the fact, that the 
arteries are so frequently found quite empty after death. 

One of the strongest proofs we have of the power which the capillaries 
possess of drawing blood to themselves, is derived from the phenomena 
observed in vascular tumours. If scratched, or slightly wounded, these 
tumours frequently bleed to an alarming extent ; while the division of the 
arteries which lead to them, and the removal of the whole mass, is 
attended with a comparatively small loss of blood. This is further 
exemplified in the familiar operation of opening the temporal artery. If the 
artery be only partially divided, and its connection with the capillaries stili 
to a certain degree maintained, it bleeds copiously ; but if it be cut across, 
and the connection wholly destroyed, it ceases to bleed altogether. Pro- 
fessor Smith, of Philadelphia,* amputated a leg below the knee, for dry gan- 

* This fact is mentioned in a monograph which I received from America many years ago. 
Unluckily, I have mislaid it, and cannot call to mind the author's name. He advocated views 
similar to those I have here attempted to establish, and to him I am indebted for the argument 
derived from the placental circulation. 



INFLAMMATION — CAPILLARY CIRCULATION. 413 

grene of the foot and ankle. The great arteries were found wholly altered in 
their structure, being, as it were, converted into tubes of bone. Although 
pressure was completely removed from the femoral artery, and no means 
whatever were used to suppress the hemorrhage, the quantity of blood 
lost did not amount to half a tablespoonful. At the same time the action 
of the heart was vigorous, and the pulse at the wrist of the ordinary 
strength and fulness. Now in this case some blood must have been 
passing through the tibial arteries before the operation, for there was some 
circulation in the leg down as far as the ankle, and the collateral arteries, 
or anastomosing branches, were not enlarged. If we refer to the phe- 
nomena of wounds which engage arteries, we shall find, as I have already 
stated, when alluding to the operation of opening the temporal artery, 
that the wounded artery of an injured limb bleeds much more than the 
same artery of an amputated one. Hence it is that branches which would 
pour out a large quantity of blood, if merely wounded, sometimes do not 
require a ligature at all, although their divided orifices open on the surface 
of a stump. 

Another instance in which the attracting power of the capillaries may 
be seen, is in cases where portions of an amputated finger have again 
united, of which we have several examples. In this case the fluids 
effused by the upper cut surface are absorbed and circulated by the vessels 
of the amputated tip. But one of the most remarkable proofs of the 
position I have laid down is derived from the circulation of the blood in 
the placenta. In this instance the impetus which the blood possesses in 
the umbilical arteries has been attributed to the vis a tergo derived from 
the heart of the fetus. Eut after the detachment of the placenta, after 
the birth of the foetus, the pulsation in the cord ceases, first at the placenta, 
and then at the umbilicus of the infant. After this period a section of the 
cord is not followed by any thing like the amount of hemorrhage which 
might be expected from the division of vessels of such diameter, and in 
many instances there is no loss of blood whatever. Now why does the 
flow of blood cease in the umbilical arteries? The vis a tergo is as 
powerful after birth as before, and operates on blood in tubes free from 
obstruction. It cannot be attributed to cold, for the circulation continues 
in every part of the infant ; nor to exhaustion, for the foetus loses no 
blood, and its circulation is now independent of the mother. Neither is 
it owing to the action of the lungs, which are said to divert the blood 
from the placenta ; for although a greater portion of blood is carried to the 
lungs after than before birth, yet this would not account for the total ces- 
sation of the circulation in vessels so large as the umbilical arteries. The 
-explanation, therefore, commonly given is not capable of being proved. 
From the facts which I have brought forward, it would appear that the 
organic vital actions of the placenta depend upon its own life, and that 
when this body is detached from the uterus, it of course dies, and the 
functions of its capillary system cease. The suction-power of the small 
vessels then continues no longer to assist the vis a tergo in carrying blood 
through the umbilical arteries, and the circulation declines, first at the 
placenta, and finally in the umbilical arteries, at their junction with the 
abdomen of the foetus. 

Such are the arguments derived from experiments and pathology in 
favour of the capillaries having a direct influence on the circulation. 
Those which may be borrowed from comparative anatomy are still 



414 CLINICAL MEDICINE. 

stronger. If we look to the vegetable kingdom, we shall find that the 
force with which the sap, i. e. the blood of plants, circulates in their ves- 
sels is very great. Hales and Dutrochet have proved this by direct expe- 
riment. If a vine be cut down in spring to the distance of three feet 
from the ground, it throws out sap with such force as to raise twenty-one 
feet of water. In other experiments this power was found capable of 
raising thirty-two and a half inches of mercury, or thirty-five feet five 
inches and three-quarters of water ; and thirty-eight inches of mercury, or 
forty-three feet three inches and one-third of water. To effect this pro- 
digious circulation, as it takes place in plants, the force must be very 
great, for we know that it is capable of raising from the ground a large 
quantity of water, combined with nutritious principles, to the top of the 
loftiest palm or forest tree — in fact, to an altitude of one hundred and fifty 
feet. Now in what organs does this power reside ? There is no central 
organ in plants, nothing like a heart — nothing like large arterial tubes. 
How, then, is the ascent of the nutritious fluid accomplished ? Let us 
study the phenomena for a moment, and we shall find sufficient evidence 
to satisfy ourselves that the fluid circulating in each part of the tree is 
brought to it chiefly by the action of the vessel of the part itself. I do not 
mean to deny the great power which the spongioles of the roots, acting as 
capillary systems, exert in driving the fluids they absorb through the tubu- 
lar vessels of trees ; this power is no doubt aided by the buds and leaves, 
whose capillaries, when acted on by a proper temperature, discharge their 
vital functions with activity, and are capable of drawing the sap to the 
extremities of the branches. Thus in the case of a vine observed by 
Richerand, one branch of which had crept into a smith's shop, this branch 
remained in leaf, or rather threw out fresh leaves in winter, while all the 
other branches continued quite bare. Again, cut off a branch of a living 
plant and place it in water, how actively does it absorb the water, and 
endeavour to prolong its existence. In winter this attraction of the ulti- 
mate ramifications of plants ceases, but returns again with the genial 
warmth of spring, when the buds begin to expand. Phenomena analo- 
gous to these are also observed in many animals. There are numerous 
tribes of animals possessing an active circulation, which have no heart 
whatever. Thus the Medusae and Echinodermata, which must enjoy an 
active circulation, as is proved by their rapid growth, have no heart. In 
the Holothurio tubulosa, Cuvier has traced vessels going to the organs of 
respiration (pulmonary arteries), and vessels coming from the same (pul- 
monary vessels), as also a system of arterial and venous tubes destined to 
carry on the general circulation, but no heart. There are numberless 
examples of this arrangement to be found in the animal kingdom. In fact, 
a great deal of the motion observed in the fluids of the human body is 
effected by other means besides the heart, and those means are the powers 
possessed by the capillary vessels and membranous tissues of the body, 
which, by virtue of an unknown law, aid materially in the circulation. 

You perceive, then, gentlemen, that my views are quite opposed to 
those who assert, that in inflammation the enlargement of the capillaries 
is passive. Dr. Hastings and Dr. Philip allow that the capillaries dilate 
during inflammation, but they attribute this effect to debility. This, 
however, is a mere assumption. The phrases, passive and debilitated, 
put one in mind of another hackneyed expression founded alike on fallacy, 
namely, indolent ulcers. Now there is nothing more active than what is 



INFLAMMATION — CAPILLARY CIRCULATION. 415 

termed an indolent ulcer. It manufactures more secretion, uses more 
blood, and produces more pain than any equivalent portion of the same 
tissue throughout the body, and yet it is termed indolent ! It is so with 
regard to the capillaries. It is said that in inflammation the capillary 
vessels are obstructed, and their force weakened. What is the real fact? 
Take an instance of conjunctivitis. What do you observe here ? The 
affected membrane is swollen, its nervous sensibility exalted, its thermo- 
metrical temperature increased, its secretion augmented. Are any of these 
symptoms of debility ? I think they can hardly be looked upon as such. 
The increase of pain, heat, and fluid secretion — the augmentation in size 
— all the phenomena, in fact, are opposed to the theory of debility. There 
is no passive dilatation or weakness ; the capillaries enlarge and dilate 
from increased, and not from diminished action ; red blood finds its way 
into vessels which before received only white ; and unusual secretions 
occur in the affected parts. The capillaries have the initiative : with them 
commences the enlargement, which afterwards extends to the smaller arteries, 
and from these to the larger branches. 

Under ordinary circumstances, the capillary circulation continues some 
time after the heart has ceased to beat, for the capillaries belong to that 
class of tissues which possess an inferior degree of vitality ; and it has 
been shown by Bichat that such tissues survive those of a higher degree 
of organization. Hence, the capillaries continue to act for some time 
after the heart has ceased to beat ; and as it is a law that the capillaries 
of the lungs will not transmit non-arterialized blood, the systemic veins 
become gradually distended, while the systemic arteries are emptied, so 
that, after death, we seldom find any blood in the latter. 

A very curious case, recently published by Dr. Houston, supports very 
strongly the views which I have put forward in this lecture.* Dr. Houston 
had a very remarkable case, in which the circulation had ceased in one 
of the lower extremities. The foot, and afterwards the leg, were attacked 
with dry gangrene, of which the patient died. No obstruction was found 
in the vessels after death, and the ordinary injection passed readily into 
all the arterial ramifications. The arteries were all pervious, and appa- 
rently natural in their texture. Now, if the circulation of the limb had 
depended on the arteries alone, it would not have ceased so completely. 
Some time ago I attended, with Mr. Cusack, a patient from the North of 
Ireland, a young lady of rather delicate constitution, who was attacked 
at a certain hour every day, in a very singular way. The circulation in 
one of her legs seemed almost to cease, and the limb became remarkably 
pale and cold. This state of the limb would last for ten or twelve hours, 
and then an alteration took place ; the leg became hot and painful, and 
its temperature became so disagreeable to the patient that she was obliged 
to keep the leg outside the bed-clothes, and have it constantly wetted with 
cold water and vinegar. During all this time the action of the heart was 
natural and the circulation of the rest of the body unaltered. Here we 
have a certain portion of a limb at one period of the day quite cold and 
pale, and at another extremely hot and painful. How can this be said to 
depend on any vis a tergo ? The true explanation of the matter is, that 
it depends on a periodic affection of the nerves, capillaries, and smaller 
arteries of the part. 

* The reader is referred to a note to the lectures on Fever for the details of this interesting 
case. 



416 CLINICAL MEDICINE. 

Such, gentlemen, are some of the arguments in favour of the supposi- 
tion that the capillary vessels exercise a remarkable influence over the 
circulation. There are other proofs which I shall not touch on at present, 
as the more immediate business of the hospital prevents me from deviating 
any further from the path of strict clinical investigation. You may ask, 
perhaps, why I have entered on this subject at all, or why I have dwelt 
so long on matters which appear to possess only a mere theoretical interest. 
Because I am persuaded that much error exists with respect to the nature 
of the forces employed in carrying on the circulation, and because I think 
it of the most vital importance that you should be in possession of correct 
principles to guide you in the numerous emergencies attendant on the 
treatment of disease. The human body in its development from a lower 
to a higher degree of organization, loses none of its character, it ascends, 
retaining in its more perfect development all that it possessed in an inferior 
state. In the first stage of its development it possessed a diffused nervous 
and vascular system. It then acquired small nervous strings and capillary 
vessels, and finally larger arteries, larger nerves, nervous centres, and a 
heart. In the same way its circulation commenced, beginning in the 
smaller vessels and extending to the larger, aided by the vis a teigo, but 
independent of it in a remarkable degree. From this view of the sub- 
ject, it follows that, in many cases of disease, we are to look to the forces 
which regulate the circulation of the part affected, and not to any vis a 
tergo, or propelling power of the heart. The physician and surgeon must 
study the life of each part, in attempting to estimate its morbid conditions. 
It was a want of proper knowledge on this subject which led to so many 
errors in practice. Among these I may mention the treatment of Egyp- 
tian ophthalmia, in which it was thought necessary to drain the patient of 
blood, for the purpose of subduing a mere local inflammation. In truth, 
the treatment of local inflammation, whether affecting external organs, as 
phlegmon, carbuncle, erysipelas, or internal parts, as pleurisy, peritonitis, 
&c, can never be properly understood, until the old doctrine, which (by 
teaching that the vis a tergo was every thing in inflammation) led to a too 
general use of venesection, has been laid aside, and sounder opinions 
adopted. 

Postscript. — Since the preceding lecture was delivered, this subject 
has been handled by many physiologists, and the majority of them enter- 
tain the same views which I then, and for many years before, advocated. 
I shall now quote the opinions of Dr. Carpenter, the most modern and 
distinguished of our British physiologists; their importance is sufficient 
apology for inserting them in this place. 

u VVe now come to the last head of the inquiry into the powers which 
convey the blood through the capillary system — that, namely, which con- 
cerns the agencies existing in the capillaries themselves. Many discus- 
sions on this subject may be found in physiological writings, and it has a 
bearing so immediate on one of the most important questions in pathology 
— the nature of inflammation — that it deserves the fullest attention. The 
chief question in debate is the degree in which the capillary circulation 
is influenced by any other agency than the contractile power of the heart 
and arterial system ; — some physiologists maintaining that this alone is 
sufficient to account for the capillary circulation ; and others asserting that 
it is necessary to admit some supplementary force, which may be exerted 



CAPILLARY CIRCULATION. 417 

either to assist, retard, or regulate the flow of blood from the arteries into 
the veins. We shall first inquire what evidence there is of the existence 
of any such force: and, when led to an affirmative conclusion, we shall 
examine into its nature. No physiological fact is more clearly proved 
than the existence, in the lower classes of animals, as well as plants, of 
some power independent of a vis a tergo, by which the circulating fluid 
is caused to move through their vessels. This power seems to originate 
in themselves, and to be closely connected with the state of the nutritive 
and secretory processes, since any thing which stimulates these to increased 
energy accelerates the circulation, whilst any check to them occasions a 
corresponding stagnation. It may be convenient to designate this motor 
force by the name of capillary power, it being clearly understood, how- 
ever, that no mechanical propulsion is hence implied. On ascending the 
animal scale, we find the power which, in the lower organisms, is diffused 
through the whole system, gradually concentrated in a single part, — a new 
force, that of the heart, being brought into operation, and the circulation 
placed, in a greater or less degree, under its control. Still there is evi- 
dence that the movement of the blood through the capillaries is not en- 
tirely due to this, since it may continue after the cessation of the heart's 
action, may itself cease in particular organs when the heart is still acting 
vigorously, and is constantly being affected in amount and rapidity by 
causes originating in the part itself, and in no way affecting the heart. 
The chief proofs of these statements will now be adverted to. 

"The movement of the blood in the capillaries of cold-blooded animals, 
after complete excision of the heart, has been repeatedly witnessed. In 
warm-blooded animals, this cannot be satisfactorily established by experi- 
ment, since the shock occasioned by so severe an operation much sooner 
destroys the general vitality of the system; but it may be proved in other 
ways to take place. After most kinds of natural death, the arterial sys- 
tem is found, subsequently to the lapse of a few hours, almost, or com- 
pletely, emptied of blood ; this is partly, no doubt, the effect of the tonic 
contraction of the tubes themselves: but the emptying is commonly more 
complete than could be thus accounted for, and must therefore be due to 
the continuance of the capillary circulation. Moreover, when death has 
taken place suddenly, from some cause (as, for instance, a sudden electric 
shock), that destroys the vitality of the whole system at once, the arterial 
tubes are found to contain their due proportion of blood. Further, it has 
been well ascertained, that a real process of secretion not unfrequently 
continues after general or somatic death; urine has been poured out by 
the ureters, sweat exuded from the skin, and other peculiar secretions 
formed by their glands ; and these changes could not have taken place 
unless the capillary circulation were still continuing. In the early embry- 
onic condition of the highest animals, the movement of blood seems to be 
unquestionably due to some diffused power, independent of any central 
impulsion: for it may be seen to commence in the vascular area, before 
the development of the heart; the first movement is towards, instead of 
from the centre, and even for some time after the circulation is fairly 
established, the walls of the heart consist merely of vesicles loosely at- 
tached together, and can hardly be supposed to have any great contractile 
power. 

44 The last of these facts may be said not to have any direct bearing on 
the question, whether the capillary power has any existence in the adult 
28 



418 CLINICAL MEDICINE. 

condition ; but the phenomena occasionally presented by the foetus at a later 
stage appear decisive. Cases are of no very unfrequent occurrence in 
which the heart is absent during the whole embryonic life, and yet the 
greater part of the organs are well developed. In most, or all of these 
cases, however, a perfect twin foetus exists, in which the placenta is in 
some degree united with that of the imperfect one; and it has been custo- 
mary to attribute the circulation in the latter to the influence of the heart 
of the former, propagated through the placental vessels. This supposition 
has not been disproved (however improbable it may seem) until recently; 
when a case of this kind occurred, which was submitted to the most care- 
ful examination by an accomplished anatomist." 

As the case alluded to, viz., that by Dr. Houston, is given in the pre- 
ceding lecture, I shall not again introduce it, but pass on to the conclu- 
sions which Dr. Carpenter deduces from it. " It is evident," he says, "that 
a single case of this kind, if unequivocally demonstrated, furnishes all the 
proof that can be needed of the existence, even in the highest animals, of 
a capillary power, which, though usually subordinate to the heart's action, 
is sufficiently strong to maintain the circulation by itself, when the power 
of the central organ is diminished. In this, as in many other cases, we 
may observe a remarkable power in the living system to adapt itself to 
exigencies. In the acardiac foetus, the heart is never evolved : and the 
capillary power supplies its place up to the period of birth, after which, 
of course, the circulation ceases for want of due aeration of the blood. It 
has occasionally been noticed that a gradual degeneration in the structure 
of the heart has taken place during life, to such an extent that scarcely 
any muscular tissue could at last be detected in it, without any such inter- 
ruption to the circulation as might have been anticipated." 

"It is equally capable of proof on the other hand, that the capillaries 
may, by an influence peculiar to them, afford a complete check to the cir- 
culation of a part, even when the heart's action is unimpaired, and no me- 
chanical impediment exists to the transmission of the blood. Thus, cases 
of spontaneous gangrene of the lower extremities are of no unfrequent oc- 
currence, in which the death of the tissues is clearly connected with a local 
decline of the circulation, and in which examination of the limb after its 
removal^ shows that both the larger tubes and the capillaries were pervi- 
ous ; so that the cessation to the flow of blood could not be attributed to 
any impediment, except that arising from the cessation of the same power 
which exists in the capillaries, and is necessary for the maintenance of the 
current through them. The most remarkable evidence on this point, how- 
ever, is derived from the phenomena of asphyxia, which will be more 
fully explained in the following chapter. At present, it may be stated as 
a fact which has now been very satisfactorily ascertained, that, if admis- 
sion of air into the lungs be prevented, the circulation through them will 
be brought to a stand, as soon as the air which they contain has been, to 
a great degree, deprived of its oxygen, or rather has become loaded with 
carbonic acid; and this stagnation will, of course, be communicated to 
all the rest of the system. Yet, if it have not continued sufficiently long 
to cause the loss of vitality in the nervous centres, it may be renewed by 
the admission of air into the lungs. Now, although it has been asserted 
that the stagnation is due to a mechanical impediment, resulting from the 
contracted state of the lungs in such cases, this has been clearly proved 
not to be the fact by causing animals to breathe a gas destitute of oxygen 



CAPILLARY CIRCULATION. 419 

so as to cause asphyxia in a different manner, the same stagnation result- 
ing as in the other case. 

" The influence of prolonged application of cold to a part, may be 
quoted in support of the same genera! proposition ; for, although the 
calibre of the vessel maybe diminished by this agent, yet their contraction 
is not sufficient to account for the complete cessation of the flow of blood 
through them, which is well known to terminate in the loss of their 
vitality. 

" Many of the tacts which indicate the influence of the capillaries on 
the amount and rapidity of the circulation through them, have been 
already adverted to It is a general fact, unquestioned by any physiolo- 
gist, that, when there is any local excitement to the processes of nutrition, 
secretion, &c, a determination of blood towards the part speedily takes 
place, and the motion of the blood through it is increased in rapidity ; 
and although it may be urged that this increased determination may not 
be the effect, but the cause, of the increased local action, such an opinion 
could not be sustained without many inconsistencies with known facts." 
If the phenomena which have been here brought together be considered 
as establishing the existence, in all classes of beings possessing a circu- 
lating apparatus, of a capillary power which affords a necessary condition 
for the movement of the nutritious fluid through those parts in which it 
comes into more immediate relation with the solid, the question still 
remains open as to its nature. That the capillaries possess a contractile 
power, in a far higher degree than do the large arteries, and more easily 
excited than that of the smaller, appears scarcely to admit of doubt ; 
though to what it is due, may be reasonably questioned. It has been 
recently asserted by Schwann, that they possess the same kind of fibrous 
tissue in their walls as do the large vessels ; and this cannot be regarded 
as improbable. It is not possible, however, that their contractility could 
have any influence in aiding the continuous motion of blood through 
them, unless it were exercised in a very different manner from that of 
which observation affords us evidence ; for when we are microscopically 
examining the capillary circulation of any part, it is at once seen that the 
vessels present no obvious movement, and that the stream, now rendered 
continuous by the elasticity of the arteries, passes through them as through 
unelastic tubes. The only method in which the contractility of the 
capillaries could produce a regular influence on the current of blood 
would be an alternate contraction and dilatation, or a peristaltic move- 
ment ; and of neither of these can the least traces be discerned. Hence 
we should altogether dismiss from our minds the idea of any mechanical 
assistance afforded by the action of the capillaries to the movement of the 
blood. That the contractile coat of the capillaries has for its office to 
regulate the calibre of the vessels, can scarcely be doubted ; but circula- 
tion, as is shown by the effects of stimulating injections, which, if thrown 
into the vessels before their vitality has been lost, will not pass through 
the capillaries. It would appear, therefore, to be through their action on 
this coat that local stimuli occasion a contraction of the capillaries ; their 
effect, however, is different from what might have been anticipated : for, 
instead of the capillary circulation being retarded it is accelerated, at 
least, until an abnormal condition results from their continued operation. 
Here, again, is another evidence, that something different from mechanical 
power must be the agent that operates in all the foregoing cases. 



420 CLINICAL MEDICINE. 

" The nature of this agent is at present very obscure ; and it may not 
be in our power for some time to unveil it. The conditions of its action, 
however, lie open for investigation ; and it appears from the foregoing 
facts, that a very simple and constant expression of these may be given. 
Whilst the injection of blood into the capillary vessels of every part of 
the system is due to the action of the heart, its rate of passage through 
those vessels is greatly modified by the degree of activity in the processes 
to which it should normally be subservient in them. The current being 
rendered more rapid by an increase in their activity, and being stagnated 
by their depression or total cessation. This is little else than a modifica- 
tion of the ancient aphorism — ubi stimulus, ibi fluxus. Thus it seems 
that 4 the capillaries possess a distributive power over the blood, regulating 
the local circulation, independently of the central organ, in obedience to 
the necessities of each part. If this be true, it is evident that the dilatation 
or contraction of the capillaries will only have a secondary influence on 
the movement of the blood through them. The former condition is usually 
an indication of diminished vital energy ; and when it is observed, it is 
almost invariably accompanied by a retardation or partial stagnation of the 
current ; on the other hand, the application of a moderate stimulus, which 
excites the contractility, accelerates for a time the motion of the blood, 
by rendering more energetic that reaction between the fluids and the 
surrounding tissues, which is the condition that really has the most influ- 
ence over the current. It is not enough to object to such a doctrine, that 
we know nothing of the mode in which this reaction affects the movement 
of the blood ; since we are equally ignorant of the modus operandi of many 
other causes, whose real existence is fully acknowledged, as for instance 
the effect of a stimulus applied to a motor nerve, in causing contraction 
of the muscles supplied by it."* 

In the Edinburgh Medical and Surgical Journal, for July, 1842, the 
reader will find an admirable paper by Dr. Holland, of Sheffield, on 
1 The Forces by which the Blood is circulated in Capillary Vessels. ' 

The author goes through all the arguments that have been advanced to 
prove that the circulation through these vessels is entirely due to the 
force of the heart, and he shows most satisfactorily how very irreconcile- 
able such doctrines are with facts of every-day occurrence. At the end 
of the paper he mentions an experiment, which I believe to be unobjec- 
tionable, and, if possible, even more conclusive than Dr. Houston's mon- 
ster ; it proves beyond doubt that the circulation through the capillaries 
is entirely owing to a vital property of these vessels, and independent of 
the influence derived from a vis a tergo. We shall allow Dr. Holland to 
speak for himself, " The umbilical vein conveys arterial blood from the 
placenta to the foetus, the umbilical arteries convey venous blood from the 
foetus to this organ. The origin and termination of these two classes of 
vessels in the placenta are involved in much obscurity. No direct con- 
nection is traced between them. Whatever opinions may be held con- 
cerning the functions of this organ, or its relations to the uterus, it will 
scarcely be doubted that the vein terminates in capillaries, and that the 
arteries originate in the same kind of vessels. It is not our intention to 
examine the phenomena of foetal circulation, but to allude to one striking- 
peculiarity, viz., the circulation of blood in the umbilical vein. This 
fluid is transmitted from the placenta to the foetus without the aid of any 

* " Principles of Human Physiology, p. 417." 



SCARLET FEVER. 421 

propulsive organ. The capillaries are, indeed, the only source of motive 
power shown to exist, and hence the placenta separated from the uterus, 
appeared capable of determining the influence of the capillaries, and the 
efficiency of it in urging the blood through the long capacious vein. To 
institute the experiment a placenta was procured, twenty minutes after 
separation from the uterus, and placed, with the exception of the cord, in 
a bladder, which was immersed in water at the temperature of 100° Fah- 
renheit. The free extremity of the cord, at the same moment, was 
elevated to an angle of 30°, resting on the edge of a glass, and at the 
distance of a foot from the placenta. At the commencement of the expe- 
riment no blood escaped from the vein, but in two minutes from the im- 
mersion, it began to flow, and continued for about twenty minutes, and 
at this time it was found that the glass had received above an ounce." 

" Here, then," continues Dr. Holland, " is an experiment, much less 
unexceptionable in its character than any with which we are acquainted, 
demonstrating the power of the capillaries to carry on the circulation, not 
only in their own complicated network of vessels, but in the larger ves- 
sels, and which ultimately terminate in a capacious vein ; and the diffi- 
culty to the motion of the blood was intentionally increased by the eleva- 
tion of the whole cord above the level of the placenta. Had this organ 
been immersed without the bladder, the absorption or imbibition of the 
water would have invalidated the experiment. The water is employed 
as an external stimulant for the purpose of maintaining, what may be con- 
ceived to be, the natura-l temperature of the placenta. 

" The flow of the blood in this experiment, in our opinion, arises 
entirely from the influence of the capillaries. The stimulus of the water 
causes the blood to excite them to contraction, and the escape of it is not 
opposed by any impediment. We cannot imagine that the experiment 
produces any important modification in the conditions of the blood. The 
water is not absorbed, nor is the temperature of it elevated above the 
heat of the body. The consideration of the circulation in this case is not 
complicated by circumstances acting a tergo, or in advance of the blood ; 
nor by the agency of respiration, or the struggles of an animal, in torture 
or placed in a constrained position." 

With the above experiment I shall conclude what I have to say on the 
subject of the capillary circulation. 



LECTURE XXXVI. 



SCARLET FEVER. 



It is my intention to-day to make a few observations on the scarlet fever 
■which now prevails as a destructive epidemic in Dublin, and many other 
parts of Ireland.* The history of such epidemics is very interesting, and 
tends to shed much light, not only upon the changes which diseases un- 
dergo, but upon the fluctuations of medical opinions and treatment. In 
the year 1801, in the months of September, October, November, and 
December, scarlet fever committed great ravages in Dublin, and continued 

* These lectures were delivered during the session of 1834-35. 



422 CLINICAL MEDICINE. 

its destructive progress during the spring of 1802. It ceased in summer, 
but returned at intervals during the years 1803-4, when the disease 
changed its character ; and although scarlatina epidemics recurred very 
frequently during the next twenty-seven years, yet it was always in the 
simple or mild form, so that I have known an instance where not a single 
death occurred among eighty boys attacked in a public institution. The 
epidemic of 1801-2-3-4, on the contrary, was extremely fatal, sometimes 
terminating in death, as appears by the notes of Dr. Percival, kindly 
communicated to me, so early as the second day. It thinned many fami- 
lies in the middle and upper classes of society, and even left, not a few 
parents childless. Its character seems to have answered to the definition 
of the scarlatina maligna of authors, for a description of which I beg leave 
to refer you to the Cyclopaedia of Practical Medicine, where you will find 
an article on the subject by Dr. Tweedie. In making this reference, 
however, I do not wish to be understood as expressing my unqualified 
approbation of the article in question, for I must in candour confess that 
it falls far short of what we might have expected from a physician of Dr. 
Tweedie's learning and experience. The long continuance of the period 
during which the character of scarlet fever was either so mild as to re- 
quire little care, or so purely inflammatory as to yield readily to the judi- 
cious employment of an antiphlogistic treatment, led many to believe that 
the fatality of the former epidemic was chiefly, if not altogether, owing to 
the erroneous method of cure then resorted to by the physicians of Dublin, 
who counted among their numbers not a few disciples of the Brunonian 
school ; indeed, this opinion was so prevalent, that all those whose me- 
dical education commenced at a much later period, were taught to believe 
that the diminished mortality of scarlet fever was entirely attributable to 
the cooling regimen, and to the timely use of the lancet and aperients, 
remedies interdicted by our predecessors. This was taught in the schools, 
and scarlet fever was every day quoted as exhibiting one of the most 
triumphant examples of the efficiency of the new doctrines. This I my- 
self learned — this I taught ; how erroneously will appear from the sequel. 
It was argued, that had the cases which proved fatal in 1801-2 been 
treated by copious depletion in their very commencement, the fatal de- 
bility would never have set in, for we all regarded this debility as a mere 
consequence of previous excessive reaction. The experience derived 
from the present epidemic has completely refuted this reasoning, and has 
proved that, in spite of our boasted improvements, we have not been more 
successful in 1834-5 than were our predecessors in 1801-2. 

Before I detail more particularly the symptoms that accompany the pre- 
sent epidemic, I wish to enter a little at large into the subject of the 
changes and variations which the same disease is observed to undergo at 
different periods of time. This is a topic which occupied some of the 
master minds of antiquity, and upon which the greatest of modern physi- 
cians, the illustrious Sydenham, bestowed considerable labour. It has 
been too much neglected of late, and consequently I consider it my duty 
to call your attention to it, and I cannot do this better or more forcibly 
than by communicating to you a literal translation which I have made 
from the German of my friend Dr. Autenrieth's observations on this sub- 
ject. The task of translation is always not only difficult but irksome ; but 
if, as in the present instance, I can by this means convey to you valuable 
information not before presented to my class, or to the public in English, 



SCARLET FEVER. 423 

I never decline the labour. What I am now about to read is, indeed, 
most important, and well deserves the deep attention of every practical 
physician. 

The third cause, connected with time and capable of modifying diseases, 
is of" infinite importance, both in a theoretical and practical point of view, 
but has seldom attracted much attention. Tts existence is attested by its 
effects alone, for its nature remains unknown. I allude to the constitutio 
morborum stationaria, first noticed by Sydenham, but. since his time, 
nearly forgotten, or else confounded with the permanent influence of the 
seasons, or the accidental atmospherical changes spoken of above. All 
diseases, contagious and non-contagious, acute and chronic (the latter, 
however, seldom, except when attended with some degree of general ex- 
citement), have been observed to preserve a certain constitution or general 
character, which continues for a number of years in succession, with occa- 
sional interruptions, until it is displaced by another constitution of a dif- 
ferent character. Thus, during one period, diseases are remarkable for 
being frequently accompanied by a sensation of extreme weariness, sud- 
den sinking of the strength and vital powers, unpreceded by any evident 
marks of excitement, and attended by a disposition to pass into true 
typhus. During another period, the tongue is in general loaded with a 
thick white or yellowish coat, and many other symptoms of derangement 
in the digestive organs, such as a bitter taste, costiveness, or diarrhoea, are 
constantly observed. 

During a third period, diseases are characterized by a remarkable degree 
of vascular excitement, an evident tendency to local determinations, a 
frequent formation of morbid productions ; in a word, by all the symptoms 
of inflammation. 

It is not known whether the transition from one of these periodic con- 
stitutions to another takes place suddenly or gradually ; but the latter 
supposition appears more probable, except when the transition is accom- 
panied by unusually great atmospheric changes. The erysipelatous affec- 
tion which, both in England and Germany, succeeded the gastric and 
accompanied the first appearance of the inflammatory period, seems to 
have been an example of the gradual transition. Accurate observations 
are still wanting to determine whether this periodic constitution is con- 
fined to certain parts of the world, or extends over the whole, and whether 
its different species follow each other in a regular order of succession. If 
their order of succession should at any time be determined, it will enable 
the physician to foretell the character and most appropriate treatment of 
future diseases. The above question cannot be answered without very 
great labour spent in the investigation of the history of diseases in all ages 
and all countries, and are therefore foreign to the present work. 

The general indications of course vary with the nature of the prevailing 
constitution, and, consequently, during one period stimulating remedies, 
during another alvine evacuations, and during a third venesection and the 
antiphlogistic plan, will constitute the most effectual treatment. 

This very circumstance has caused much confusion in medical opinions, 
and has occasioned the reputation and the downfall of many an infallible 
system, each of which is in its turn consigned to oblivion, and perhaps 
again revived as a novelty at some future period. The English boast 
much of the astonishing improvements in science, and deride the ignorance 
of their predecessors, regardless of ihe old proverb — "Every thing has 



424 CLINICAL MEDICINE. 

its day." Whenever, therefore, the periodic constitution undergoes an 
alteration, they either obstinately uphold their usual plan of treatment to 
the manifest injury of their patients, or else blindly embrace some system, 
to them new, but which really rests upon ancient and established princi- 
ples. In general, they do not fail to make use of so much exaggeration 
in support of their opinions, and thus succeed in misleading so many, that 
none but very well informed physicians can distinguish the fallacy of their 
arguments. 

The medical history of Great Britain affords many striking proofs of the 
truth of these assertions, and is replete with examples of the singular 
obstinacy with which the English cling to opinions once formed, a circum- 
stance which has materially contributed to obstruct their attaining to gene- 
ral views and impartial conclusions. Even to this day, a warm contest 
is carried on (less, however, in books than in the debates of learned socie- 
ties) between the senior and the junior parts of the profession, the former 
still inclining to Brunonianism, while the latter attribute nearly all dis- 
eases to inflammation. Both, indeed, appeal to experience to prove the 
justice of their principles, and seem entirely to forget that while the pro- 
priety of their practice, as applied to particular cases, remains unimpeached, 
the very nature of the diseases themselves may have been changed. A 
summary review of the character assumed by diseases during the last 
twenty years, both in England and other countries, will perhaps afford a 
solution of this question. About the end of the last, and during the three 
or four first years of the present century, the proportion of nervous fevers 
to other diseases was as one to eighteen in Plymouth (Woolcombe), as 
one to sixteen in London (Willan), as one to ten in Newcastle (Clarke), 
and in Liverpool one to five (Curry). Nor was this scourge of mankind 
less severely felt upon the continent, where typhus, and diseases closely 
allied to it, committed extensive devastations, particularly during the epi- 
demics of Erlangen, Jena, Kiel, Ratisbon, and Vienna. Cadiz and Se- 
ville were at the same period depopulated by the yellow fever, and Eu- 
rope in general suffered much from repeated visitations of influenza. An 
inclination to a sudden sinking of the vital power, unpreceded by violent 
reaction, and unaccompanied by any marked symptoms of a gastric or 
inflammatory nature, constituted at that period the characteristic form of 
acute diseases, which were always preceded and attended by an unac- 
countable degree of debility. Stimulating and tonic medicines obtained, 
therefore, much celebrity, and every physician who practised during that 
period, attests the injurious or even fatal effects which were produced by 
the use of venesection, and other depletory remedies. What is still more 
remarkable, an epidemic typhoid pneumonia prevailed in many parts of 
Germany during the years 1S00-1-2, in which the speedy production of 
an inflammatory state, by means of bark and ether, was the only method 
which afforded a chance of recovery. These facts must impress every 
impartial mind with the conviction, that the constitution of diseases has 
undergone much alteration since that period, and explain why physicians 
did not then employ copious venesection, but were obliged to content 
themselves with ordinary cold effusions, acids, and mercury. 

The reign of typhus appears to have ceased with the influenza of 1804, 
when a new constitution began, at first more remarkable for the disap- 
pearance of nervous fevers and other contagious diseases, than for any 
peculiar character of its own. Catarrhal and rheumatic complaints, partly 



NERVOUS FEVER. 425 

attributable to tbe weather, prevailed for some time, and fevers of an 
intermitting type became more frequent, forming an evident transition 
from the purely typhus constitution to that of the vascular excitement of 
the following years. Some remnant of the typhus constitution was indeed 
still perceptible in the pectoral complaints which prevailed in London 
during the winter of 1804-5, and were attended with remarkable debility, 
requiring the greatest prudence in the use of the lancet. Venesection was 
indeed often entirely contraindicated, and Bateman states that it some- 
times even proved fatal. The constitution, however, soon developed 
itself more decidedly, became more universally diffused, and obliged 
physicians to relinquish their former plan of treatment and adopt other 
measures. Derangement of the alimentary canal became its prominent 
feature in the summer and autumn of 1804, and diarrhoea, terminating in 
dysentery, was often met with. 

This constitution suffered indeed a check from the cold of 1805, but it 
increased again during the following years, and afterwards became still 
more prevalent, manifesting itself by headache, a bitter taste in the month, 
a loaded yellow tongue, irregularity of the bowels, nausea, and anorexia. 
The utility of purgatives now became so obvious, that Hamilton's doctrines 
soon obtained as much celebrity as had been before enjoyed by the .stimu- 
lating system. The nervous fever at Nottingham in 1S07, the dysentery 
at London in 1808, the scarlatina at Edinburgh in 1S05, and the measles 
at the same place in 1808, all required the purgative plan of treatment, 
and calomel became the favourite cathartic. The advantage then derived 
from the use of purgative medicines is abundantly testified by the writers 
of that period. This gastric constitution appeared also on the continent, 
but its progress was less rapid there than in England, where the inhabi- 
tants live in a manner calculated to augment or even to produce a ten- 
dency to gastric diseases. There were likewise other circumstances which 
impeded the formation of this constitution on the continent. Thus in Ger- 
many, the purely nervous constitution had scarcely yielded to catarrhal 
and rheumatic affections, when it was again revived in that unhappy coun- 
try by the political occurrences of 1805-6-7. Typhus seldom, however, 
assumed the character of exquisite, for the rheumatic and catarrhal affec- 
tions with which it was mixed partook somewhat of a gastric nature, as 
was proved by the great benefit derived from the exhibition of emetics and 
calomel. This appears in accordance with the fact that the gastric consti- 
tution was more fully developed wherever the ravages of war had not ex- 
tended, although it still required less attention in the treatment than the 
rheumatic symptoms, then likewise prevalent. Thus the agues which were 
common at Tubingen about the end of 1806, commenced in general with 
pain in the belly, vomiting, and irregularity of the bowels ; a yellow furred 
tongue, headache, and tremours of the parotids, were of frequent occur- 
rence, and in general gastric symptoms were by no means rare. These 
symptoms gradually gained ground, and the reputation of ipecacuanha and 
cathartics increased in the same proportion. At Ratisbon the constitution 
was remarkably gastric in the autumn of 1809, and a nervous fever pre- 
vailed at Weimar in 1809-10, which was accompanied by bitter taste in 
the mouth, diarrhoea, nausea, and vertigo. Active catharsis was injurious 
in this epidemic, but much benefit resulted from ihe exhibition of castor- 
oil. The advantage derived about the same time in Berlin from the treat- 
ment of fevers by emetics and cooling purgatives, proved that they were 
there also complicated with gastric derangement. 



426 CLINICAL MEDICINE. 

The gastric constitution had scarcely established itself, or become pretty 
generally diffused, when a new character, viz. the inflammatory, appeared 
upon the stage, and has ever since continued, sometimes combining itself 
with the gastric to form diseases of a mixed character, such as erysipelas, 
and sometimes, when favoured by the seasons or local circumstances, rais- 
ing itself to the rank of the chief performer. With its appearance vene- 
section, which had previously fallen into disrepute, became once more a 
favourite remedy, and in the course of a few years was pushed so far, par- 
ticularly in Great Britain, that Sangrado's maxim, " C'est une erreur de 
penser que le sang soit necessaire a la conservation de la vie, on ne peut 
trop saigner un malade," seems to have been the general rule of practice. 
The same inflammatory constitution became also general in Germany, but 
there it neither attained such a height, nor required such active treatment 
as in Great Britain, where many circumstances favoured its more perfect 
development; with us it generally yielded to the use of acids, cold appli- 
cations of mercury, but in England it called for copious blood-letting. 
Even in 1810, diseases had become more inflammatory at Tubingen than 
they had been previously; but the change was still more perceptible in 
1813, when the antiphlogistic treatment required the aid of small venesec- 
tions, and nervous fevers were accompanied both by inflammation and 
derangement of the digestive organs. Erysipelatous affections were also 
frequent, and in many cases were of a marked inflammatory character. 
Erysipelas and true inflammatory fever, requiring the use of the lancet, 
were common at Ratisbon in 1811 ; Parrot exhibited acids, especially the 
acetous, with great success in the epidemic nervous fever which raged at 
Dorpat in 1812, and a diarrhoea of a bilious inflammatory nature prevailed 
at Konigsberg during the same year. This important change in the con- 
stitution became very evident in the nervous fever at Berlin in 1813, as 
well as in the formidable epidemic described by Hufeland, which ensued 
after the war, and raged in the north of Germany during that and the pre- 
ceding year. Although but a few years before the strongest stimulants 
had been necessary to obviate the paralysis which supervened even in the 
beginning of the disease, yet an opposite practice was now required, and 
antiphlogistic remedies were alone found capable of preventing the vascu- 
lar excitement from terminating in inflammation of either the head or chest. 
In short, the inflammatory constitution has been prevalent in Germany ever 
since the years 1810-11, sometimes in its pure and marked form, and 
sometimes complicated with gastric and rheumatic symptoms. 

This constitution became general at the very same period in Great Britain. 
Dr. Clutterbuck, of London, had indeed ascribed the origin of fever to in- 
flammation of the brain, so early as 1807, and about the same time Dr. 
Steiglitz, of Hanover, had recommended the antiphlogistic treatment of 
scarlet fever, in preference to the stimulating plan then in vogue. But 
as the inflammatory was then still subordinate to the rheumatic and gas- 
tric constitutions, their opinions did not gain many converts. But the in- 
flammatory constitution had increased so much in the autumn of 1809, 
and the winter of 1810, that even Dr. Bateman was obliged to prescribe 
venesection in fevers, a practice quite at variance with his former views. 
Erysipelatous inflammation became common in London, Aberdeen, and 
Leeds, and numerous cases of puerperal fever occurred in the latter towns, 
which, according to Gordon and Hey, never terminated favourably, except 
when bleeding and purgatives were employed with freedom. But it was 



NERVOUS FEVER. 427 

not until 1813, when the inflammatory constitution had fully developed 
itself, and the bad consequences arising from violent determination of blood 
to the head in nervous fever could not be averted except by decisive mea- 
sures, that venesection came into general use in Great Britain in conse- 
quence of a publication by Dr. Mills, who had prescribed it with much 
success since 1810. In the same year that truly estimable physician, Dr. 
Thompson, published his admirable work upon inflammation. Blackall 
recommended blood-letting in several species of dropsy, and Armstrong 
employed the same remedy, combined with large doses of calomel, in the 
inflammatory puerperal fever which was prevalent at Sunderland. Vene- 
section became from this time as great a favourite as ever in England, not, 
however, to the exclusion of purgatives, which were indicated by the de- 
rangement of the stomach and bowels that accompanied the inflammatory 
constitution. Both these remedies were found extremely beneficial in the 
nervous fever which was epidemic in Ireland in 1813-14; its inflamma- 
tory character being clearly evinced by a hard and full pulse during its 
first stage, and a violent determination of blood to the head, by which the 
headache and raving are increased, while its gastric type was not less 
strongly marked by tenderness of the epigastrium, costiveness, or else fre- 
quent and unnatural alvine discharges, together with a loaded tongue and 
bilious vomiting. The latter symptoms were, in Dr. Grattan's opinion, of 
such importance, that he gave a decided preference to the purgative plan. 
The fever, which had previously been confined to Ireland, became gene- 
rally diffused over the rest of Great Britain alter the famine of. 1816, and 
continued without intermission for four years. Its inflammatory character 
being peculiarly favoured, both in England and Scotland, by the habits of 
the inhabitants and the situation of these countries, venesection attained 
an unexampled degree of celebrity, notwithstanding the representations of 
the Irish physicians, who used that remedy with more moderation. It was 
soon believed that there is, literally speaking, no disease whatever in which 
the lancet ought not to be used, and, as the human mind is ever prone to 
extremes, it was soon generally considered, both in England and Scotland, 
to be a well-founded pathological inference, " there is but one species of 
fever, viz. the inflammatory, and consequently venesection is the only 
true anti-febrile remedy. Such is the case in England at present, and it 
must have been so always, and in every part of the world.*" I flatter my- 
self, however, that the preceding observations and statements of facts, 
drawn from authentic sources, sufficiently negative these assertions, and 
establish the real existence of a change in the constitution of diseases, not- 
withstanding what Dr. Duncan once said to me, "that such changes existed 
only in the imagination of physicians." 

It is now twelve years since Dr. Autenrieth, in his Account of the State 
of Medicine in Great Britain, made the foregoing interesting observations ; 
and to me it appears that the history of the diseases which have since 
prevailed affords convincing proofs that the then inflammatory constitution 
has again subsided, and is now replaced by a typhous type: indeed, it 
cannot be denied that a very great difference exists not only between the 
present and the former scarlatina, but also between the fever of the pre- 
sent day and that which prevailed shortly before Dr. Autenrieth pub- 
lished. But this is too important a question for us to decide, without 
more reflection and thought than 1 have been able to bestow on it, and 
without more facts than I have been able to collect. The opinion I have 



428 CLINICAL MEDICINE. 

brought forward I do not wish to be received as established ; I look upon 
it as probably well-founded, but as yet not proved, except so far as to 
merit further consideration and excite further discussion. 

Indeed, I have for the present been obliged, by the pressure of other 
engagements, to postpone a more accurate examination of this subject, 
and a more severe scrutiny of the facts which just now crowd into my 
memory; but I conclude with remarking, that the wide-spreading epi- 
demic influenza, which lately visited the whole of Europe, including the 
British Isles, was not only truly remarkable, both for the violence of the 
feverish symptoms and of the local congestions of the chest and heart, 
which accompanied its attack, but likewise for the unexpected relation 
which it was found to bear to al! measures of active depletion. I appeal 
to the profession for their testimony on this matter — I ask whether all our 
preconceived opinions as to the a priori indications for venesection, leech- 
ing, and purging, were not found to be contradicted by the effects of 
these remedies in the epidemic influenza of 1833. The sudden manner 
in which the disease came on, the great heat of skin, acceleration of the 
pulse, and the intolerable violence of the headache — together with the 
oppression of the chest, cough, and wheezing — all encouraged us to the 
employment of the most active modes of depletion, and yet the result was 
but little answerable to our expectations, for these means were found to 
induce an awful prostration of strength, with little or no alleviation of the 
symptoms. In some who were thus treated, recovery was protracted and 
doubtful, and the strength was not restored for several months. Indeed, 
nothing was more curious than the length of time which was necessary 
for some persons, in order to recruit their 'strength after an attack of this 
influenza, although that attack had not continued more than a few days, and 
had been judiciously treated, without blood-letting or unnecessarily debi- 
litating remedies. I have known some who lapsed into a cachectic state 
of long-continued debility from which they never recovered ; for, while 
thus reduced, they fell victims to the first acute complaint which seized 
them. The influenza above referred to fully confirmed the opinion T had 
long entertained, that in acute diseases debility and exhaustion of the 
vital power are by no means in every case either caused by, or propor- 
tioned to, a state of previous excitement. This opinion received further 
support from the symptoms and phenomena exhibited by the Asiatic cho- 
lera, in which the stage of debility and collapse commenced, and too often 
closed, the scene. Why do I dwell upon these occurrences, and why 
have I so frequently referred to the opinion above expressed ?' Simply 
because the prevalence of the contrary opinion laid the foundation for the 
injudicious and exclusive application of the lancet, and of the antiphlo- 
gistic method generally, in Britain, and was, consequently, the cause of 
working excessive mischief. 

I have already mentioned that the disease called scarlet fever assumed 
a very benign type in Dublin soon after the year 1804, and continued to 
be seldom attended with danger until the year 1831, when we began to 
perceive a notable alteration in its character, and remarked that the usual 
undisguised and inflammatory nature of the attack was replaced by a con- 
cealed and insidious form of fever, attended with great debility. We 
now began occasionally to hear of cases which proved unexpectedly fatal, 
and of families in which several children were carried .off; still it was not 
until the year 1834 that the disease spread far and wide, assuming the 



SCARLATINA. 429 

form of a destructive epidemic. The nature of the disease did not appear 
in the least connected with the situation or aspect of the patient's dwell- 
ing, for we observed it equally malignant in Rathmines as in Dublin, on 
the most elevated habitations on mountains as in the valley of the LifTey. 
It raged with similar violence at Kingstown, and the neighbourhood of 
Killiney and Bray. The state of the weather seemed to exercise no in- 
fluence either upon its diffusion or its symptoms, which continued to ex- 
hibit equal virulence, no matter whether it was wet or dry, warm or cold, 
calm or stormy. The contagion seemed to ant as a more deadly poison 
on the individuals of some families than upon those of others, and, con- 
sequently, when one member of a family had died, there was always 
much reason to fear for the others when attacked. At first I thought that 
its greater severity in such cases could be traced to a strumous habit, but 
subsequent experience did not confirm this suspicion, for the most scro- 
fulous family I ever saw went through the disease without a death, whereas 
in some others the mortality was great, although not a single indication 
of a strumous diathesis could be detected. Many parents lost three of 
their children, some four, and in one instance which came to my know- 
ledge, five very fine children were carried off. As usual in such epide- 
mics, the degree of intensity with which different persons were attacked 
varied exceedingly, some exhibiting the mildest form of scarlatina sim- 
plex, which required no treatment, and scarcely confinement to the room, 
while the majority were severely affected. When the disease was vio- 
lent, it assumed one or other of the following forms: — 

First. — It at once produced not merely fever with sore throat and head- 
ache, but such violent congestion of the brain, and determination to the 
head, as occasioned convulsions and apoplectic coma on the first or second 
day. This happened to a fine young woman of robust habit in Werburgh 
street, to whom I was called by my friend Dr. Brereton. She was at- 
tacked with convulsions on the second day, and died comatose on the 
third. In her the scarlet eruption was extremely vivid and general, a 
fact I notice as a proof that the congestion of internal organs was not 
caused by any retrocession of the eruption. In truth, as will appear here- 
after, the worst cases had the most general and most intense cutaneous 
efflorescence. When this tendency to the head took place in so violent 
a manner at the very onset, the patient was seldom saved ; sometimes, 
however, very active measures of depletion, general and local, relieved 
the brain, and the case then went on favourably. This happened in a 
young gentleman residing in Upper Baggot street, to whom I was called 
by the late Mr. Nugent, of Merrion row. When the scarlet fever attacked 
a person subject to epileptic fits, the tendency to the head was increased 
by the epdeptic habits, and the fits of convulsions at once supervened. 
Thus in the case of a gentleman, aged twenty-two, who had been for 
several months treated by Mr. Colles and me for epilepsy, the fits com- 
menced on the second day of scarlatina, and continued with frightful 
violence until the fifth day, when they proved fatal. In a young lady 
residing near Black Rock, to whom I was called by Dr. Wilson, precisely 
the same thing occurred. She had been subject to epilepsy for many 
years, and when the scarlet fever commenced she was at once seized with 
frequently-recurring fits, which, in spite of the most active measures, ended 
in fatal coma on the fifth day. 

In the second form of the disease which I noticed, the symptoms were 



430 CLINICAL MEDICINE. 

exceedingly violent and intense from the beginning, and the disease set in 
with the usual symptoms of severe exanthematous pyrexia, remarkable in 
the very commencement for the violence of the accompanying headache 
and spinal pains, and for the great irritability of the stomach and bowels. 
Indeed one of the very first symptoms in such persons was nausea, 
vomiting, and bowel complaint. Large quantities of recently secreted 
bile were thrown up, and the patient passed frequent, at first semi-fluid 
and afterwards fluid stools, curdled green or saffron yellow, and evidently 
composed of bile suddenly effused into the intestinal canal, with a copious 
and hurried secretion of mucus from the internal membrane of the bowels, 
and mixed with some true fecal matter. It was surprising what quanti- 
ties were thus thrown up, and passed from the bowels by some during 
the first day or two of the disorder ; neither the constant repetition of the 
nausea, and vomiting, nor the abundance of the discharge from the 
stomach and bowels, in the slightest degree mitigated either Ihe violence 
of the fever or of the headache, or seemed to prevent the full formation 
of the eruption. It was curious to observe that this obstinate vomiting 
and purging w T as unaccompanied by the slightest epigastric or abdominal 
tenderness ; during its continuance the belly became fallen and soft. In 
fact its cause was situated not in the belly, but in the brain, a fact I did not 
perceive until I had had an opportunity of watching the progress of five 
or six such cases. It depended on cerebral irritation and congestion, 
and was in nature very similar to the irritability of stomach and bowels 
which so often accompany, and too frequently mask the progress of acute 
hydrocephalus. As soon as I had become aware of the pathological 
relations of this vomiting and purging, I did not confine my endeavours 
to check these symptoms to measures intended to act directly on the 
stomach and bowels, such as effervescing draughts, chalk-mixture, stupes, 
leeches to the epigastrium, &c. &c. I changed my plan of treatment, and 
turned my attention to the state of the cerebral circulation. Having in a 
former lecture referred to this topic, and having explained to you the 
manner in which derangement of the stomach and bowels of a properly 
gastric origin is to be distinguished from disorder of the digestive appa- 
ratus, originating in a sympathetic derangement of function, itself caused 
by a morbid condition of the brain, and having already pointed out the 
importance in practice of not confounding these tw 7 o states, one or other 
of which is so common in the commencement of violent fevers, phleg- 
masia, and exanthemata, I shall not at present dwell any longer on this 
subject. The second form of scarlatina w r as likewise remarkable for the 
violent excitement manifested from the very beginning in the circulating 
system, and in the production of animal heat. The pulse at once rose to 
above 100, it was seldom less than 120, and in many cases, particularly 
in young people, it ranged from 140 to 150. I have never in any other 
disease witnessed so many cases of excessively rapid pulse. In general 
the pulse in this form was regular, but in two cases it became irregular ; 
one was that of a gentleman living in Upper Mount street, whom I attended 
with Sir Henry Marsh ; his pulse became intermitting and irregular on the 
third day, and continued to be more or less thus affected for about a week. 
This gentleman was attacked with subsultus, delirium, jactitation, and 
various nervous symptoms, at a very early period, and complained con- 
stantly of his throat and head. The former was violently inflamed, and 
his skin was covered with a bright red eruption. On the ninth day he 



SCARLATINA. 431 

was seized with convulsive fits of great violence, and which returned 
very frequently during the night; his case appeared utterly hopeless, and 
yet he perfectly recovered. In a young lady, whose case is detailed by 
Dr. Nolan, great irregularity and intermission of the pulse commenced 
about the eighth day, and continued during the state of danger ; she also 
recovered. Of course irregularity of the pulse was in many not so much 
a symptom of disease as of approaching death, but then the state of the 
patient could not be mistaken, judging from all the other circumstances 
of the case. The acceleration of the pulse abated in all when an evident 
improvement in the general condition took place, but in few did the pulse 
become quite natural for many days after a favourable change, and in none 
did it fall to its usual standard in the course of twelve or twenty-four hours, 
as it not unfrequently does after the crisis of continued fevers ; in fact, 
the scarlatina never ended with a well-defined crisis. As to the tempera- 
ture of the body, I have already observed that in the cases [ am now- 
describing it was from the first considerable, and continued elevated until 
a very short period before death. Both the pulse and the heat of skin, 
however, were very easily reduced in energy by the use of the lancet or 
by the repeated application of leeches, and it was not uncommon to 
observe that even the judicious use of these means induced a general 
coldness of surface, very great sinking of the strength, and a faltering 
state of the pulse. This was remarkably the case in a young lady whom 
I attended along with Mr. Wilkinson, in Black Rock, and also in one o{' 
the family whose cases are related by Dr. Nolan. In both, these effects 
were very obstinate and alarming, for reaction was not restored until after 
the lapse of more than twelve hours; both finally recovered. The pulse 
was sharp but not strong, and resembled the pulse of great irritation 
rather than that of true inflammation. The most distressing symptom at 
the commencement of this form of scarlatina was the sore throat ; the 
fauces were violently inflamed, and deglutition consequently much im- 
paired, while a general soreness was felt in the back of the head and 
neck; urgent headache was complained of by all, and from the second 
day the eyes became suffused; great restlessness, anxiety, jactitation, 
moaning and interrupted raving soon made their appearance, and in 
many, sleep was banished or utterly broken by startings and delirium 
before three or four days had elapsed. The eruption had now arrived at 
its height, which it did with great rapidity, dating from the first moment 
of its appearance, so that the skin, everywhere covered with a scarlet 
eruption, resembled in appearance the hue of a boiled lobster. Tn these 
violent cases the efflorescence was perfectly continuous, and never broken 
into spots or patches ; the skin appeared as if evenly dyed with one 
uniform colour ; the surface of the tongue was likewise much affected 
with the same exanthematous redness, and soon became foul and after- 
wards dry and parched. The sudden drying of the tongue on the fifth 
or sixth day indicated in this form a rapid aggravation of the disease, and 
death in several cases was observed to follow this change in less than 
twenty-four hours, when it was, as in a yonng gentleman Mr. Rumley 
and I attended in French-street, accompanied by a sudden acceleration of 
the pulse and increase of the jactitation and delirium. In this form the 
brain and nervous system seemed to be the parts which suffered most, 
and many became insensible for several hours before death ; others had 
convulsions; when the patient survived the seventh day there was a fair 



432 CLINICAL MEDICINE. 

chance of recovery, but many, too many, died on the fourth, fifth, or 
sixth day. 

After I had witnessed a few examples of this form of scarlatina, I con- 
sulted with several of my friends and colleagues, and we determined to 
use the most active measures of depletion in the very first instance that 
occurred to us. A case was not long wanting. Sir Henry Marsh and I 
were engaged in prescribing for some children labouring under the epi- 
demic, in a bouse in Pembroke-street, where our attention was directed to 
a fine boy, six years old, and hitherto perfectly healthy, who was, while 
we were paying our visit, attacked with the first symptoms of the com- 
plaint ; we immediately resolved that as soon as the stage of rigor and 
collapse which preceded the febrile action had passed, to visit him again 
and act energetically, if circumstances seemed to permit it. Accordingly 
we came again in the course of a few hours, and found reaction already 
established, attended with vomiting, purging, and headache. The sore 
throat, too, was much complained of, and there was great tenderness of 
the external fauces. We ordered relays of leeches, eight at a time, to 
the neck, for the purpose of relieving both the throat and brain, and we 
administered James's powder and calomel internally. On the next day 
the skin was burning in spite of a copious loss of blood from the leech- 
bites, the eruption vivid and already established, the pulse 140, and there 
had been little or no sleep. Relays of leeches were again ordered, and 
persevered in until considerable and lasting faintness was produced, and 
yet no impression seemed to be thereby made on the disease ; no abate- 
ment of its virulence seemed to be the result, for the raving became more 
incessant on the second night, and on the third day suffusion of the eye 
commenced, and the tongue became parched. Shaving of the head, the 
most industrious application of cold to the scalp, and various other reme- 
dies were in vain applied ; the pulse became weaker, the breathing 
quicker,, the strength failed rapidly, raving and delirium gave place to 
insensibility and subsultus, and the patient died on the fifth day. In this 
case depletion was applied at once and most decidedly, for we blanched 
and weakened the boy by loss of blood as far as it was possible to ven- 
ture, and yet the disease was not in the least degree checked, nor the 
symptoms even mitigated. 

A fine boy, thirteen years of age, was attacked in the county of Wick- 
low, where he was placed under the care of a very judicious practitioner, 
who did not use either venesection or leeches, but relied chiefly on the 
exhibition of diaphoretics, particularly antimonials. The boy died on the 
seventh day, having suffered much from delirium, subsultus, want of 
sleep, &c. His brother, who was one year older, and a very strong boy, 
was seized with the disease in Dublin, and placed immediately under my 
care. I had the advantage of Mr. Ilumley's assistance, and we deter- 
mined to prevent the supervention of the cerebral symptoms, if it were 
possible to do it by means of antiphlogistic treatment: we failed, and 
our patient died on the sixth day. In short, in this form of the disease, 
where the pulse, without becoming strong, at once became extremely rapid, 
bore venesection badly, and required great caution even in the applica- 
tion of leeches ; the nervous symptoms only appeared accelerated by the 
system of depletion, although the heat of the skin suggested its employ- 
ment. The derangement of the brain and nerves in this form depended 
on something more than the violence of the circulation, and originated in 



SCARLATINA. 433 

something altogether different from mere cerebral inflammation or con- 
gestion. What that something was I cannot even conjecture; but it was 
probably the result of an intense poisoning of the system by the animal 
miasma of the scarlet fever. Every tissue of the body seemed, if I may 
use the expression, equally sick, equally overwhelmed, and it is probable, 
that the capillary circulation in every organ was simultaneously deranged. 
It was not gangrene of the throat which proved fatal, for in this form it 
never occurred ; it was not inflammation of any internal viscus, for such 
was not found on post-mortem examination of the fatal cases ; but it was 
a general disease of every part. In many, another state of things, which 
required to be carefully distinguished from that just described, existed, 
and the disease was evidently attended with an inflammatory state of the 
constitution, requiring energetic measures. In such cases the symptoms 
were severe in the commencement, the throat very sore, the efflorescence, 
however, not quite so sudden or so perfect, and the pulse never near so 
quick, never excessively rapid, and always strong and distinct. Such 
bore bleeding and leeching well, and experienced from their use almost 
immediate alleviation of the sore throat, headache, and restlessness, and 
were not much weakened by the depletion. It must be confessed, that 
it was often exceedingly difficult to determine, a priori, whether the de- 
pletory system ought or ought not to be tried. Where doubt existed, my 
custom was to try moderate leeching, and from its effects I judged of the 
propriety of persevering. 

The disease very frequently occurred in a third form, more singular 
still than the two first, and much more insidious in its commencement. 
This form was evidently very common in the epidemic scarlet fever de- 
scribed by Withering, as cited by Dr. Tweedie. In this form the disease 
was ushered in by the usual symptoms of pyrexia, together with sore 
throat, slight headache, and in due time a very moderate and normal 
eruption. The symptoms continued moderate ; the patients, after the first 
few days, slept tolerably well during the night, had no raving, and were 
quiet during the day. About the fourth or fifth day all the febrile symp- 
toms had so far subsided, that a most accurate examination could detect 
nothing urgent, nothing in the slightest degree either alarming or calcu- 
lated to excite the least anxiety in the patient's condition. His skin be- 
came nearly of the natural standard, his thirst diminished, and the pulse 
was now scarcely accelerated ; a calm nearly complete, in fact, seemed 
to have followed the first onset of the disease ; and on entering the room, 
the physician might easily be deceived, as I myself was more than once, 
into the pleasing hope, that all danger was past, and that perfect recovery 
might confidently be anticipated. This hope was, in truth, founded on 
such circumstances as we can usually rely on ; for who would prognosti- 
cate danger where his little patient, sitting up in bed, and perhaps eating 
a dry crust with some appetite, had a placid countenance, and had enjoyed 
a night of tranquil sleep ? Regular alvine evacuations, diminution of 
thirst, sore throat, headache, and fever, together with the normal state of 
the cutaneous eruption, all conspired to confirm a favourable prognosis ; 
and so matters proceeded, the family dismissing all apprehension as to 
the result, and the physician most probably discontinuing his attendance 
about the seventh day, in the belief that all danger was over, and that his 
interference was no longer necessary. Matters proceeded thus until the 
eighth or ninth day, when a certain degree of restlessness was observed 
29 



434 CLINICAL MEDICINE. 

to occur, and in the morning a slight return of fever might be noticed. 
Then it was that a peculiar train of symptoms set in. The nostrils assumed 
a sore and irritated appearance about the edge of the alae, and a serous 
moisture began to flow from their internal cavities. Sore throat was again 
complained of, the skin became hot, great debility and prostration of 
strength came on suddenly, a painful tumefaction commenced in the region 
of the parotids and submaxillary glands. This tumefaction increased 
rapidly, becoming every day harder, more elevated, diffused, and exceed- 
ingly tender, but without much redness. In the course of a few days it 
surrounded the neck like a collar, and being attended with swelling of the 
face, the poor little patient's countenance was sadly disfigured. In the 
mean time the discharge from the nose had increased considerably, and 
become more viscid and fetid ; the internal membrane lining the nasal 
passage was affected throughout, its entire surface everywhere inflamed 
and tumefied, so that a snuffling sound was produced when the patient 
breathed through his nose : at length the discharge increased to such a 
degree that the nostrils became completely impervious to the air in 
breathing. The state of the throat generally began to alter for the worse 
at the very commencement of this change; and a similar inflammation, 
attended with an ill-conditioned secretion of lymph and fluid, occupied 
the entire surface of the mouth and tongue, and at last spread deep into 
the pharynx. While this was going on, the fever freshly lit up, at once 
exhibited the most decided symptoms of the worst form of typhus and 
subsultus, constant muttering, raving, anxiety, want of sleep, restlessness, 
moaning mingled with an occasional screech, reminding one of that which 
is so ominous in hydrocephalus. Great difficulty was now experienced in 
swallowing, and the drink was frequently spirted out of the mouth after 
a vain attempt at deglutition. Matters now proceeded rapidly from bad 
to worse, and at last, after much suffering, death closed the scene, being 
preceded for many hours by a state of extreme restlessness, during which 
it was impossible to determine whether the patient was still sensible. The 
swelling of the neck went on increasing to the last, but seldom exhibited 
any tendency to point ; it continued, on the contrary, everywhere hard, 
or, at most, became indistinctly softened, or, to use a technical phrase, 
u boggy." When cut into, no matter was found ; blood, serum, and a 
diffused cellular slough, not separated from the living tissues, were ob- 
served on making the incision. 

I shall now read to you a letter I received on the subject of scarlatina, 
from Mr. O'Ferrall. His observations are extremely valuable, more espe- 
cially those which are made towards the termination of the letter, where 
he describes a most important sequela of scarlatina not hitherto mentioned 
by any writer. 

" My dear Sir, — In reply to your letter, I have the pleasure to send 
you a few brief notes of my experience of the scarlatina of last autumn 
and winter. 

" Of seventeen cases of which I possess notes, four occurred in adults, 
three in children under four years of age, and the remainder at different 
ages between the latter and fourteen or fifteen years. I seldom saw the 
cases in the commencement. The mode of attack was occasionally simi- 
lar to that of common sore throat followed by rigors ; sometimes violent 
pyrexia and shiverings, with intolerable headache, and even delirium, 



SCARLATINA. 435 

preceded by other signs. In some few cases, the efflorescence first at- 
tracted notice, the fever in these instances being throughout so mild as 
scarcely to demand attention. 

" The progress of the disease was various, but usually bore a relation 
to the character of the incipient fever. In general, the fever increased 
in intensity as the disease advanced, or as new parts became engaged ; 
but this was not always the case. In two instances which I saw in a state 
of great vital depression on the third or fourth day, I was assured that the 
early fever was very high, although it had passed rapidly into the typhoid 
state. 

" The danger sometimes appeared to arise from the condition of the 
entire system, sometimes from that of important parts. Of two cases 
which I saw when dying, one was sinking like a person in typhus fever; 
the other, a boy thirteen years old, was moribund in the coma, which 
succeeded to violent phrenitic delirium. The latter case was remarkable 
in this, that the phrenitic state occurred while the eruption was in its 
prime, the whole body retaining its deep scarlet colour until a short time 
before his death. The disease in this instance set in with delirium, which 
had been subdued, I have reason to believe, by the most active means. 
Death occurred in one instance from croup, the disease of the throat hav- 
ing passed into the trachea and bronchial tubes. In another, sloughing 
of the fauces, with low fever, carried off the patient on the sixth day. 

" In several, who ultimately recovered, life was seriously endangered 
by local inflammatory attacks. In one instance, a girl about seven years 
old, enteritic symptoms sprang up suddenly while the patient was in a 
very weak state, and were with difficulty subdued. In another, a boy 
ten years old, acute pain in the region of the heart occurred when the 
eruption was on the decline ; it was accompanied by short cough, palpi- 
tations, dyspnoea, rapid, though not irregular pulse, and sudden accession 
of fever. There was no perceptible frottcment, but the action of the heart 
was violent, and there was acute pain on pressure. It yielded to leech- 
ing, followed by calomel, with James's powder, till the gums were slightly 
touched. 

"Another patient, a girl twelve years old, narrowly escaped the effects 
of sloughing of the throat. Croup occurred in two instances, in which, 
notwithstanding the opinions of M. Trousseau, I could not doubt its origin 
in scarlatina. It happened, no doubt, in cases which had exhibited the 
diphtheritic patches, without much surrounding inflammation on the ton- 
sils, but the eruption was sufficiently marked to remove all obscurity. 
One child, who recovered, ejected the false membrane (which I still pre- 
serve) in a tubular form, and presenting a cast of the trachea a little be- 
yond its bifurcation. In the child before mentioned, who died, patches 
of false membrane were also ejected ; but she sank exhausted, and the 
disease was afterwards discovered to have extended far into the bronchial 
ramifications. 

11 Although the treatment was generally antiphlogistic, this plan was 
not always applicable, even in the commencement of the disease. In all 
instances which I had an opportunity of observing, it was necessary to 
watch the effects of local bleeding. It was easy to pass the boundary of 
relief, and then most difficult to repair the loss, and meet the symptoms of 
exhaustion when they had actually set in. Wine and diffusible stimuli 
were often required from this cause alone, even when the cases had no- 
thing of the malignant or typhoid character in their nature. 



436 CLINICAL MEDICINE. 

" Tepid sponging appeared in many instances preferable to cold, and 
I think the soothing effects were of longer duration. Reaction, and the 
distressing sense of burning heat, did not appear to recur so soon as when 
cold fluids were employed. Purgatives, except of the mildest kind, were 
not well borne, but cooling diuretics were clearly indicated, and, when 
persevered in, had, in many cases, the apparent effect of anticipating the 
sequelae of the complaint. 

u The ulcerations and sloughing of the throat were treated by nitrate 
of silver, alum, and the chlorides, according to their states. But none of 
these applications were to be depended on, when the colour of the fauces 
was intensely red, unless a few leeches had been previously applied. In 
one gentleman, twenty-eight years of age, free leeching, externally (to 
the number of forty), failed in removing the sense of suffocation or ena- 
bling him to swallow. A few leeches applied to the inside of the nostrils 
was followed by copious bleeding and immediate relief. The latter ex- 
pedient was indicated by the tumid state of the velum and pituitary mem- 
brane, the stertorous breathing, and complete occlusion of the nares. 

" Its mode of spreading in families was uncertain. It sometimes at- 
tacked children within a few days of each other ; at other times, a fort- 
night has elapsed before I was again requested to see a new patient. 
Some children escaped the disease altogether. 

" Among the sequelae which I had occasion to see, diarrhoea occurred 
in two or three instances, chronic bronchitis in one, and anasarca in four. 
The urine was slightly albuminous in two of the latter cases before the 
face and limbs began to swell ; in the other two it exhibited this charac- 
ter when the disease was formed, but I did not see them previously. The 
treatment of the anasarca was antiphlogistic and diuretic, and succeeded 
in restoring three to perfect health ; the fourth still remains an invalid, but 
not from this cause ; the apex of the right lung affords evidence of tuber- 
cular disease. 

" I have now to mention a peculiar affection of the neck, which I have 
not before seen in connection with scarlatina, but of which four cases have 
occurred during my observation of the epidemic in question. 

" Case 1. — About the beginning of August, 1834, I was requested by 
my friend, Dr. Davy, to see a young girl, ten years old, in Upper Baggot 
Street. Her convalescence was tedious, some degree of fever still existing 
at the end of six weeks from the commencement of the attack. But her 
principal complaint was severe pain of the right side of the neck, close to 
the head, and extending as high as the vertex on the least motion of the 
part. She could not raise the head from the pillow without putting a 
hand at each side for its support, and when taken out of bed, instinctively 
sought a resting-place for the chin. The face was awry, its vertical 
diameter passing from above downwards, and from right to left. Pos- 
teriorly, the upper cervical vertebrae were curved, the convexity of the 
curve being situated a little to the left of the middle line ; there was con- 
siderable swelling of the soft parts covering the bones. Pressure here 
was intolerable, and the least attempt to rotate the head occasioned 
severe pain. Deglutition was now tolerably easy, but there had been con- 
siderable difficulty of swallowing during the early period of the complaint. 
There was here obviously a carious state of the articulation of the atlas 
and dentata, and we did not expect to remove the curvature. Perfect 
rest was, however, enjoined, and the usual remedies employed with a 



SCARLATINA. 437 

view to arrest the further progress of the disease. She gradually reco- 
vered her health, and is now lively and well grown, but the curvature is 
permanent. 

" Case 2. — Early in August, 1834, Mary Inglesby, of Russell Place, 
aged 7, was sent to me by Mr. Long, of Summer Hill. She was confined 
to bed in scarlatina for a fortnight. At the end of this time she was taken 
out of bed, and then the head was observed to be turned to one side. It 
was now five weeks altogether from the beginning of the disease, and the 
parts were still in the same state. The face was awry. She complained 
of pain in the concavity of the curve and that side of the head, and could 
not bear the slightest motion or shock. Leeches were prescribed, and 
calomel given afterwards in doses of a grain, three times a-day, till the 
gums were touched. As soon as this effect was produced, the pain sub- 
sided, and the pain gradually acquired its natural position. Her recovery 
was complete. 

" Case 3. — A younger brother of Mary Inglesby was subsequently under 
the care of Mr. Long, for scarlatina. The same state of the head and 
neck were detected on the thirteenth day, and treated by Mr. Long, on 
the same plan as that adopted in the former case. The pain disappeared 
as soon as the mouth was made sore, and the position of the head became 
natural. He is now in good health. 

" Case 4. — I met Mr. Edgar, of Arran Quay, in February last, in the 
case of a young gentleman about six years old, whose convalescence from 
scarlatina was tedious, and in whom the difficulty of swallowing persisted 
after the redness of the fauces was removed. On taking him out of bed 
it was remarked that he was quite unable to keep the head erect. The 
symptoms were similar to those of the two last cases, but in a milder 
degree. A few leeches were applied, and evaporating lotions instantly 
used to the part, on account of considerable local heat. The leeching 
was repeated in a day or two, but as the symptoms yielded rapidly, and 
as he had some tendency to diarrhoea, calomel was not employed. In 
about a fortnight, the natural position of the head and neck was restored. 

" I can offer no better explanation of the occurrence of this affection, 
during the progress of scarlatina, than by supposing that the inflammation 
of the fauces and back of the pharynx was propagated to the adjoining 
parts. In all those cases there had been marked and prolonged difficulty 
of deglutition, as a symptom of the disease ; and it is to this circumstance 
I am desirous of calling attention, as affording an index for a careful 
review of the condition of the spine during the period of convalescence. 
Should a child be observed to lie more on one side than the other, and 
evince an unwillingness to be disturbed, it would be an additional reason 
for suspecting a tendency to this complaint. Believe me, Dear Sir, yours 
very truly, 

" JOSEPH M. O'FERRALL. 

"Rutland Square, West, 30th July, 1835." 

Since the preceding lecture was delivered, the disease has raged every 
winter and spring with undiminished virulence, and has resisted, as before, 
nearly every kind of treatment. A letter w r hich I received from Dr. 
Cumming, of Armagh, stating that scarlatina had rarely been witnessed 
in that city since he settled there, eleven years ago, and that he had 
never seen the malignant form of the disease, induced me to forward a 



438 CLINICAL MEDICINE. 

circular to the principal medical men in the provinces, to ascertain if the 
disease prevailed in their respective districts, and if it had assumed the 
fatal form we had observed in so many instances in Dublin. 

I shall now briefly lay before the reader the principal facts contained 
in the answers to my queries. Dr. Geoghegan, of the Kildare Infirmary, 
says, that during his residence there, for ten years, scarlatina never pre- 
vailed as an epidemic, and the sporadic cases he met with were exceed- 
ingly mild.* Dr. Astle, of Edenderry, relates the same. Dr. Wood- 
ward, of Kells, has not seen it epidemically, but isolated cases were re- 
markably fatal, some dying within the first twenty-four hours. Dr. Clif- 
ford, of Trim, mentions that it has latterly been prevalent in his district 
and very fatal. Dr. Clarke, of Rathdrum, states that it has been on the 
increase for the last three years, but has been very mild. The letter of 
Dr. Lloyd, of Malahide, is so important that I shall introduce it in full. 



u 



"Malahide Dispensary, August 20, 1842. 
Dear Sir, — In reply to your circular relative to the prevalence of 
scarlatina in my district, I beg to say, the year ending May, 1839, no 
case occurred; May, 1840, one case in an adult ; May, 1841, no case ; 
May, 1842, thirty-two cases are registered, three of which were fatal, 
one 24 hours after the appearance of the eruption ; the others were a 
brother and sister, aged eight and six, scrofulous, and after a period of 
from 12 to 16 days, they died of diseased brain and abscesses in the 
throat. Since May, six cases have been under my care. The only cases 
of moment were those mentioned above as fatal, and some of the same 
family in which the urgent symptoms were extensive ulceration of the 
fauces — they recovered rapidly. During the past year, there were nu- 
merous instances of the disease, but so slight that the individuals were 
under no restraint ; so that I was not applied to, save occasionally to 
treat some of the sequela?. 

" I may here allude to a curious fact. My district joins, on one side, 
that of Baldoyle ; on the other, Swords ; in both, epidemic diseases have 
frequently appeared for the last 25 years, with virulence, and after a long 
period commenced in Malahide district, in a mild and subdued form ; 
many of the poor inhabitants are aware of the circumstance. 
"Believe me yours, sincerely, 

" HANS LLOYD. 

" To R. J. Graves, Esq., M.D." 

* Since I received the above communication from Dr. Geoghegan, he has sent me the fol- 
lowing note : — 

" My bear Sir, — Since T replied to your circular, relative to scarlatina, many cases of it 
have occurred at .Newbridge, four miles from this, on the Dublin road, and, from the number 
and rapidity of the deaths, I must suppose of the malignant kind. It was nearly confined to 
the children of the labouring class, and not having the dispensary there, I did not see them. I 
am, however, induced to state the condition of a boy, aged five years, I saw a day or two since, 
for the first lime, although he then was three weeks ill. On the right temple was a large 
ecchymosis, about two inches in diameter ; arterial blood trickling from the nose, mouth, and 
ears ; he was greatly emaciated, and quite sensible, had diarrhoea and the hemorrhage only 
from the preceding day ; the cervical glands were enlarged, but had not suppurated, nor was 
there anasarca or dropsy ; he died the following morning. Being asked while driving past to 
see the child, and finding him so wretched an object, I merely told the mother I did not think 
he had the slightest chance of recovery. This is, I think, the only case in which I ever saw 
hemorrhage from the ears. Believe me, my dear Sir, yours faithfully, 

« W. P. GEOGHEGAN, M.D. 

" Infirmary, Kildare, Oct. 12, 1842." 



SCARLATINA. 439 

Dr. Glover, of .Philipstown, never saw or heard of a case of scarlatina 
during the four years he has resided there. Dr. Croly, of Mountmelick, 
states, that the disease has latterly become prevalent in that locality, and 
has assumed on many occasions a malignant form. Dr. Brunker, of Dun- 
dalk, mentions, that the disease has only presented itself in one instance 
within the last five years, and was very mild. Dr. Hudson, of Navan, 
has not met with the disease often ; and during a term of eight years has 
only had one fatal case ; whilst Dr. Byron of the same town states, that 
the disease " was very prevalent, and in several localities unusually ma- 
lignant during the last two years, up to a period of about two months 
ago, when it was observed to be on the decline. At present, there are 
very few cases within twelve or fifteen miles of Navan, and these are 
less virulent, generally speaking, than formerly." From Wexford, Dr. 
Boxwell writes, that there " they have had but a few scattered cases in 
the town for the last six years, and not one fatal." In Arklow, Dr. 
Wright mentions, that scarlatina has been very prevalent in that town 
and neighbourhood for several years past, particularly 1840-41 ; but it 
did not frequently prove fatal." In Athy, as appears from the letter of 
Dr. Clayton, it has prevailed, and some of the cases have proved fatal. 
Dr. Macartney, of Enniscorthy, states, that it was prevalent and fatal 
during 1837 and 1838, and that it was, at the time of writing, breaking 
out again. The following communication from Dr. Ridley, of Tullaraoore, 
is too important to be omitted : — 

11 Tullamoore, October 17, 1842. 
" Dear Sir, — Scarlatina appeared here in the latter part of November, 
in the last year, as an epidemic, and continued to be very prevalent until 
June following. During this period it prevailed most in the month of 
March. I saw a great number of cases in this town and the neighbour- 
hood, which were mostly all of the benign or simple form. Some cases 
occurred, in full plethoric subjects, of an inflammatory nature ; but I did 
not meet with a case of the malignant or typhoid disease, such as I have 
seen in Dublin. This epidemic raged chiefly amongst children and young 
people — the oldest subject I am aware of having had it was a person of 
forty years. It commenced with rigors, lassitude, loss of appetite (in 
some cases with soreness of the throat as a first symptom), and the usual 
symptoms of approaching fever, which continued to increase until the 
third or fourth day, during which time, in some instances, the fever ran 
high, with raving and other symptoms of cerebral disturbance. The 
eruption generally appeared on the second day in the form of small dis- 
tinct spots like flea-bites, which did not run together, and declined sud- 
denly on the fourth or fifth day without desquamation. In some instances 
the character of the eruption was an efflorescence, which remained out 
until the sixth or seventh day, and was always followed by desquamation, 
The fever was equally high in both these forms of eruption, but of greater 
duration in the latter. The throat was very slightly affected in the ma- 
jority of cases, being nothing more than a slight erythematous blush on 
velum and tonsils ; however, in some robust, plethoric persons, there was 
much inflammation, demanding active treatment. The symptoms had 
usually so much subsided as to enable the patient to leave the bed on the 
sixth or seventh day. The fatal cases which I witnessed here, were caused 
by congestion of the brain, occurring on the third day, while the eruption 



440 CLINICAL MEDICINE. 

was well out and every thing appeared favourable, slight drowsiness set in, 
which was quickly followed by coma and stertor ; and in two cases death 
ensued in thirty hours from the commencement of those symptoms: they 
were all in young persons of full habit, and had no previous delirium or 
inflammatory affection of the brain. The sequelae were, anasarca (which 
was very general, and occurred after, the mildest form of the disease), 
pneumonia, bronchitis, acute rheumatism, remittent fever, enlargement of 
submaxillary and parotid glands. In one instance pneumonia proved 
fatal in eighteen hours. It was the case of a boy of nine year's old, who 
had been three weeks recovered from scarlatina. The treatment was that 
usually practised. Emetics and purgatives, diaphoretics, attending to 
ventilation, &c, were sufficient in the generality of cases. In the inflam- 
matory form, venesection, antimonials and calomel were prescribed ; when 
the throat was affected, the free application of nitrate of silver was found 
to be the best remedy. Leeches, acid gargles, application of powdered 
alum, blisters, &c, were also beneficial. When anasarca followed, it 
generally yielded to smart hydragogue purgatives; but in some cases I 
gave calomel and squill with advantage : as a prophylactic I was induced 
to try belladonna, but without success. 

" There was at this time a very prevalent inflammatory affection of the 
throat, which appeared and disappeared with the scarlatina. This dis- 
ease commenced with slight fever, stiffness of the neck and dysphagia, 
which afterwards increased to a great degree. The pharynx, tonsils, and 
velum, assumed a deep scarlet hue, and were in some cases covered with 
patches of lymph, which could be raised off with a probe, like the mem- 
brane of diphtherite. The tonsils became greatly enlarged ; also the 
parotid and submaxillary glands ; the jaw became fixed, so that the teeth 
could not be separated ; there was inability of swallowing, hurried breath- 
ing, and high fever. These symptoms increased to the fourth or fifth 
day, when the fever subsided with diaphoresis ; the jaw became relaxed, 
copious salivation came on, and the ability of swallowing was in some 
degree restored ; and, finally, in the course of eight or nine days from the 
commencement of the attack, this inflammation ended in resolution. In 
some few cases one or both tonsils suppurated, and in other still rarer 
instances, ulceration of the pharynx followed. Such are the symptoms of 
the most severe form of this disease ; but it was sometimes so mild, as 
not even to confine patients to the house. 

" At any other time this disease would have been looked on merely as 
an epidemic cynanche ; but in this instance, there was a very decided con- 
nection observed between it and the prevailing scarlatina. It was, in the 
first place, even popularly remarked, that a person who had suffered from 
this cynanche had not been afterwards attacked with scarlatina, and that 
an attack of the latter was not in any instance followed by one of the for- 
mer. It was likewise observed, that when one member of a family was 
seized with cynanche, scarlatina soon showed itself amongst some of the 
rest ; and in the same manner, when scarlatina appeared first, cynanche 
very frequently followed, so that one was considered as the forerunner of 
the other. The following few brief cases may serve to show this con- 
nection. 

" Case 1. — Master S. came home from school (where scarlatina had 
prevailed) complaining of soreness in swallowing, slight headache, and 
nausea. The next day the tonsils were enlarged, and he complained of 



SCARLATINA. 441 

greater pain in swallowing ; pulse quick, skin hot ; but no appearance of 
eruption. These symptoms remained without getting worse for three days, 
when they gradually subsided. Before he was perfectly well, scarlatina 
seized tw T o of his sisters and his father. In the former, the eruption ap- 
peared as an efflorescence and ended in desquamation ; in the latter it 
"was in the form of distinct spots, and without any subsequent desqua- 
mation. 

u Case 2. — Master O. came home from the same school with scarlatina. 
Two of his sisters and his brother were seized with it while he was ill. 
The eruption came out well in the spotted form. At the same time the 
man and maid-servant were attacked violently with cynanche, which was 
attended with high fever for several days. 

" Case 3. — Visited Mr. B. who had been suffering from severe cynanche 
for four days. He cannot articulate or swallow ; the jaw is so fixed as to 
prevent the teeth being separated to more than a quarter of an inch ; fresh 
tumefaction of the neck ; pulse quick ; skin hot and dry ; breathing hur- 
ried ; face swollen and flushed ; eyes suffused (on inquiring if any of 
the family had scarlatina, I found his son, who was lying in the same 
room, just recovering from it). After a few days, perspiration appeared 
over the surface of the body, the fever became less, and he was able to 
open his mouth and swallow a little. On first seeing the tonsils and 
velum, I found them coated over with a thick white membrane, which 
extended to the hard < palate, and could be raised off easily with the 
probe. 

"Case 4. — P. N. has been complaining of headache and nausea since 
yesterday, feels a stiffness in his throat, and fears he is getting the scarla- 
tina, as three of his children are only recovering from it. The throat 
symptoms increased to a great degree, with a smart fever attending them. 
No eruption appeared, and he was well in eight days. 

" It is now almost generally admitted that the eruption is not a neces- 
sary symptom of scarlatina, which disease may occur independently of any 
affection of the skin. In this case the throat is supposed to be invariably 
affected, and the disease has received the name of 'scarlatina faucium.' 
But it may be a matter of some difficulty to disprove this scarlatinous af- 
fection of the throat from a common cynanche : the fact of scarlatina being 
prevalent in the neighbourhood, and the probability of the infection of it 
having been in some way communicated, must in such cases be taken into 
consideration. If it be found, however, that exposure to the infection of 
one disease gives rise to the other, and that one proves a preventive of 
the other, there are fair reasons for concluding, that it is the same disease, 
in the one case affecting the skin, and in the other the throat only, 
"I am, dear Sir, yours most truly, 

"JOHN RIDLEY." 

In Waterford, Dr. Elliott announces, that for several years it has ap» 
peared occasionally in an epidemic form, sometimes assuming great malign 
nancy during the congestive stage, whilst its peculiar diagnostic charac- 
ters were as yet barely discernible. Dr. Bewley, of Moate, mentions that 
it has not prevailed in his district for eleven years, and that during the 
whole of this period he had not a fatal case. Dr, Thorpe, of Listowel, 
has seen very few cases of the disease, and has not had a single death. 
Dr. Gogerty, of Nobber (county Meath), has had many fatal cases, and 



442 CLINICAL MEDICINE. 

the disease has been very prevalent. In Pomeroy, as appears from the 
statement of Dr. Harvey, the disease has been rare and mild. Dr. Con- 
nor, of Carlow, forwarded me the following letter, which I shall here 
introduce. 

" Carlow, 8th August, 1842. 
" Dear Doctor — I delayed answering your circular (received on Fri- 
day), until I could send you the combined opinion of some other practi- 
tioners, two of whom agree with me in saying, that there is annually a 
pretty general attack of scarlatina in this district, but nearly confined to 
the juvenile and infantine portion of the community, at least we do not 
recollect many adults affected with it, and ordy one fatal case amongst 
those, and that w r as the case of a lady just confined, and whose children 
had the disease, but recovered. As to the malignancy of the type, we 
can say, that whilst five children were carried off by it in one family others 
in same house had it slightly ; and although several lost two or more chil- 
dren, numbers of families have been so slightly affected, that were it not 
that medical men recognised the disease, it would have passed aw T ay with- 
out any notice, requiring in some cases only the little patient to remain 
one day or two in bed. When many members of one family have been 
taken away, we have had reason to think that the constitution of the suf- 
ferers had more to do with the fatal result than the original type of the 
disease. Hoping that I have answered clearly and fully, I beg to remain 
yours sincerely, 

"SHEWBRIDGE CONNOR, M.D. 

" Drs. Rawson and Porter are the persons to whom I showed your cir- 
cular. Any other medical statistical information you may require I shall 
be most happy to afford or collect. 

"P.S. — I have never known or heard of a case of intermittent fever in 
this district, though some fatal cases of typhus have had pretty regular hot 
and sweating stages, several in a day, perhaps the cold fit escaped obser- 
vation. This though not bearing on your inquiry might interest you. 

"R.J. Graves, Esq., M.D." 

Dr. Long, of Arthurstown, writes as follows — 

u Arthur stown, bth August, 1842. 

"Dear Sir — During the past year I have not observed a single case of 
scarlatina, in my extensive district ; although at New Ross, which is but 
ten miles distant, the disease has prevailed in its most malignant form, and 
been attended, I understand, with frightful mortality. 

" In the summer of the year 1839, scarlatina raged here epidemically 
for some months. Its general character was at that time of a mild type, 
yet in some cases the most malignant symptoms were present. I had then 
occasion to remark what I am sure has been observed by others, namely, 
that in the same family were to be found individuals presenting well-marked 
cases of every form of the disease, from the simple fever with bright efflo- 
rescence of the skin, to the sloughing tonsils and typhoid type. 

"In many the disease appeared to attack the throat alone, presenting 
symptoms that would, under other circumstances, have been considered 
indicative of simple cynanche tonsillaris. 

"Believe me very truly yours, 

"RICHARD LONG. 

"R. J. Graves, Esq., M.D." 



SCARLATINA. 443 

Dr. Russell, Surgeon of the County Tipperary Infirmary, gives the 
following answer — 

" Cashell, August 6, 1842. 

"Dear Sir — I this morning received your letter of the 3d, stating that 
you were engaged in writing on scarlatina, and asking if it was prevalent 
in this neighbourhood during the last few years. In the year 1840, scar- 
latina was very prevalent during the spring, and assumed a most fatal form 
(I lost my wife and child by it), it appeared also to be most infectious, as 
almost every individual, except those who had the disease previously, who 
came near those infected, were seized with it. The fever was of a typhoid 
character, and the throat appeared as if affected with gangrenous erysipe- 
las. The treatment that appeared most useful was warm bathing and the 
carb. of ammonia with bark. There have been occasional cases of it here 
since, but not at all of the same fatal form. Children seemed to sink 
under it more frequently than persons of more advanced years. I remain 
yours truly, J. W. RUSSELL, 

<l Surgeon to the County Tipperary Infirmary. 

" Dr. Graves." 

In Ballina, Dr. Whittaker says, the disease has been rare and mild. 
Dr. Stewart, of Lifford, states that two epidemics have visited that dis- 
trict within the last six years ; both were very mild. Dr. Croly, of Mount- 
mellick, says, " that scarlatina has at intervals prevailed in this locality 
for the last few years. Latterly it has assumed a malignant and fatal type, 
especially among children. The eruption was of a dark hue with early 
tendency to sphacelated ulceration of the fauces and pharynx, cerebral 
congestion with coma and convulsions." 

From Dr. O'Brien, of Ennis, the following particulars were received — 

" Bellevue, Ennis, August 9, 1S42. 

" My Dear Sir — In reply to your circular relative to the prevalence of 
scarlatina in this county, I have not many observations to make, as it is 
only within the last seven or eight years that much of that disease has 
been seen here. 

" My father, who has been forty years in practice in this county, told 
me that he has seldom seen the disease, and that it never prevailed as an 
epidemic here. About seven years since a few cases appeared here to- 
gether, and it did not reappear until the spring of the year 1840, when 
it broke out in a large school in this town, and four persons died of it. 
1 was in attendance on them, and was seized with it myself, and had a 
very narrow escape. It w T as evidently brought to the school on this occa- 
sion by a boy who had just come from the King's County, and who showed 
the disease in a day or two after his arrival. It spread with such rapidity 
through the school, that (notwithstanding the greatest precaution) the 
establishment had to be broken up for some time. It again reappeared 
about Christmas in the same year, to a slight extent, was not fatal, and 
has not been seen since. I understand that it is often v^ry prevalent in 
Limerick in spring, and very fatal. 

" We admit cases of this disease into the County Fever Hospital, when 
they occur in the lower ranks, and have never remarked that it was com- 
municated from one person to another there. Believe me to be very sin- 
cerely yours, S. W. O'BRIE.s." 



444 CLINICAL MEDICINE. 

In Boyle, Dr. Hall says, it has lately been prevalent but very mild ; 
Dr. Taylor, has seen very few cases at Ferns, all of which were mild. 
Dr. Griffin, of Limerick, writes as follows — 

" 74 Georges street, Limerick, August 6, 1842. 
" Dear Sir — We had some bad cases of scarlatina in Limerick last 
winter, and about two years ago, but they were few in comparison to the 
mild cases ; and at. any time within the last eight or ten years I have not 
known it to spread extensively as an epidemic here. It has never been 
at all so prevalent as measles or hooping-cough, or even typhus fever, 
when these diseases have been epidemic. Those who died of the com- 
plaint, suffered chiefly from the sloughing of the throat, but I saw one 
young girl die last year on the third or fourth day, apparently from the 
intensity of the fever and great prostration of strength. 
" Yours, dear Sir, very truly, 

" WILLIAM GRIFFIN. 
" R. J. Graves, M.D." 

From Dr. Roe, of the Cavan Infirmary, I received the following full and 
very satisfactory particulars — 

" Cavan, 29th August, 1842. 

" Dear Sir — Being much from home, and, at the time I received your 
polite circular, very much and anxiously occupied, I could not reply to it 
immediately in the manner I wished. 

"I now beg to say, that scarlatina has been more than usually preva- 
lent during the last few months. I have only seen two cases of it in 
adults. Amongst children I cannot say that those cases I met with were 
unusually severe or unmanageable. The soreness and swelling of the 
throat, with ulceration, were also very prominent and painful symptoms 
in several cases I saw ; the sore throat appeared almost the only symp- 
tom, and the cutaneous affection very trifling and evanescent. I cannot 
say that the type of the disease here, as far as I met with it, was of a ma- 
lignant character, nor did it put on that congestive inflammatory form, 
which produces such an awfully fatal disease. I have also seen two or 
three examples of the dropsical or anasarcous symptoms, which sometimes 
succeed ; and in one very fine healthy child, which I had an opportunity 
of seeing the evening before its death, and of making a post-mortem ex- 
amination, I found the entire cellular substance of the body pervaded 
with the dropsical effusion, and a very large quantity, amounting, I think, 
to nearly a quart, effised into the thorax. From the great dyspnoea, and 
very unequal action of the heart, I presumed there must be structural dis- 
ease of the heart— which was not the case — and all the viscera, both of 
the thorax and abdomen, appeared perfectly sound, so that the dropsy was 
entirely the result or the consequence of the original disease three weeks 
before, and from which the child appeared to have perfectly recovered. 

" Scarlatina, mixed up with small-pox, has appeared also in our poor 
house, but not of a very fatal or malignant character ; and I find from the 
physician to the poor house, that the scarlatina was rather of a low type, 
and required cordials, as wine, &c, and that bleeding was had recourse to 
only in a few cases. Although the disease has been prevalent here among 
the poor and labouring classes, yet I cannot say I have seen a great many 
cases, not being now connected with any public dispensary, and the 



SCARLATINA. 445 

County Infirmary does not receive such cases. Some years ago, when it 
appeared in an epidemic, and very severe form, I had an opportunity of 
seeing much more of it, and then I found the most beneficial effects, from 
full and early bleeding ; and in two remarkable instances, one an adult 
lady, and the other a fine healthy girl, I think it put an end to the disease, 
and prevented the congestive stage from coming on. 

" I remain, dear Sir, with much esteem, yours very truly, 

" GEORGE ROE." 

It is unnecessary to give the particulars of the many letters I have 
received on this subject ; but from all may be collected the facts, that 
scarlatina has, generally speaking, prevailed to an unusual extent in Ire- 
land, for the last seven or eight years — that it has, in many instances, 
been singularly rare in districts immediately adjoining others in which it 
has been equally prevalent — that there is no geological or physical differ- 
ence in many of the localities alluded to, which can in any way account 
for these anomalies — and that we are equally at a loss to explain- its 
mildness in some districts in which it has extensively prevailed, and its 
malignity in others. 

Even in this city, during the period of its greatest virulence, whole 
families have been attacked with the mildest forms of the disease I have 
ever seen ; and I have been assured by many of the physicians connected 
with our dispensaries, that they have for a certain period met with several 
cases, all extremely mild, and suddenly the character of the disease has 
changed, and the cases then coming before them were as remarkable for 
their malignancy, and undue proportion of mortality. This was seen in 
a remarkable degree in the practice of Dr. Osbrey, of Molesworth Street, 
whose very important communication I purpose appending to the end of 
these observations. 

The reader who has studied our old authors with care, will perceive 
the identity that exists between some forms of our malignant scarlatina 
and the epidemics described by the name of the " Ulcerous Sore Throat "* 
and the " Putrid Sore Throat "\ But in these epidemics, the principal 
and fatal symptom was inflammation, and sloughing of the throat, ulceration 
of the schneiderian membrane, attended with profuse ichorous discharges, 
&c. The eruption was either disregarded, or only mentioned as a curious 
phenomenon, and death was produced by the " sore throat" But as 
was before observed, many of our cases died without a single lesion 
that we could detect — they were poisoned by the virus of the scarlatina. 

I shall here introduce the particulars of a few fatal cases that were 
lately under my care, from which the reader will probably be enabled to 
form a better idea of the malady than from the preceding description of it. 
The following notes were taken by Dr. Henry Kennedy, by whom the 
patient was first seen — 

Case 1. — u I first saw J. K , aged 14, on Friday evening, March 

22, 1842. He had been at school the previous day, but had come home 
complaining of not being well. His mother had given him an emetic of 
ipecacuanha, which not only vomited but appeared also to have purged 
him. When visited about twenty-seven hours from the beginning of his 
iilness, I found the purging had ceased, but the vomiting continued 

* Huxham 07i Fevers, page 266. London. 1772. 

■j- Fothkrgill's Works, vol. i., p. 341. London. 1783. 



446 CLINICAL MEDICINE. 

incessantly. He was throwing up quantities of dark greenish bile, and 
this occurred whether he took any drink or not. The thirst was insatiable, 
and the desire was for what was cold ; the fever ran very high, the skin 
hot, pulse 140, and when left to himself he was inclined to rave ; he 
referred his distress to the stomach, and said he believed his throat was 
sore ; on looking into the mouth the internal fauces appeared inflamed, 
and the tongue was densely loaded, but there was nothing of that specific 
nature which would lead one to pronounce on the nature of the disease. 
At this time I looked very particularly to the state of the skin, but no 
eruption was visible. His position in bed was changed every moment, 
as he said for the purpose of giving himself relief. I had intended putting 
a few leeches over the stomach, but at the patient's own urgent request 
was induced to bleed him from the arm to about §vii. A sinapism was 
applied to the epigastrium, a mouthful of cold water given frequently, 
and the extremities sponged with vinegar and water. On the following 
morning (Saturday) all the symptoms had increased in severity, the treat- 
ment of the night before had had effect but only temporarily, in fact for 
about four hours, after which all the symptoms had reappeared. In addi- 
tion the body was now covered with an eruption which could not be dis- 
tinguished from the maculae of bad typhus fever ; it was best marked, 
however, on the chest and back ; it was quite distinct on the face. The 
raving was now of a more decided character, and it was more difficult to 
make him give a direct answer. At this period Dr. Graves visited the pa- 
tient, and recommended internal stimulants with blisters to the surface. 
It is enough to add, that all treatment appeared to be quite inert, and from 
this time till the period of the patient's death, every symptom went on 
increasing, the raving becoming every hour more violent in its character, 
and the pulse rising to 170 and even 180. One or two points are, how- 
ever, worthy of notice. During the last day of life the bowels were once 
affected, the discharge was quite natural, from this moment all vomiting 
ceased. During this day also a second crop of eruption made its appear- 
ance, it was perfectly distinct from the first, being of a redder colour, and 
the spots much more circumscribed. I have often had occasion to meet 
with the same since ; it was now too that the tongue put on its character- 
istic appearance. That the nervous system was profoundly engaged 
there was but too much evidence of, for though no convulsion came on I 
observed strabismus, and the mouth was distinctly drawn to one side. 
There was also very violent fits of shuddering almost amounting to rigor ; 
the eyes were not injected at all. The entire duration of this patient's 
illness was about sixty-eight hours." 

In the patient whose case has been detailed we have a remarkable ex- 
ample of scarlatina terminating rapidly in death, without the sloughing 
of the throat, which usually caused death in the epidemics narrated by 
Huxham and Fothergill. 

Case 2. — " Miss H , a strong healthy lady, aged 28, was attended 

at the commencement of her illness by Mr. Nicholls; when I saw her, 
there was intense redness of the throat, great dysphagia, and pain in swal- 
lowing. These symptoms induced me to bleed once freely ; the blood 
was buffed and cupped to an extreme degree. After the disease had 
lasted for about thirty-six hours, an eruption of a vivid bright colour ap- 
peared. £he obtained no relief from the bleeding, the pulse became 
quicker, debility increased, and she died with symptoms of poisoning in 
less than two days." 



SCARLATINA. 447 

The occurrence of arthritis as a complication of scarlatina, we have 
frequently witnessed in the Meath Hospital. In a man named Pierce, we 
had the greatest difficulty to save both wrist-joints from ulceration. And 
in another case, the motion of the elbow-joint was almost lost from the 
effects of inflammation. 

I have noticed that when any of the viscera become engaged during 
the progress of this disease, that there is the greatest difficulty in subdu- 
ing the local disease, and that it runs its course with great rapidity; this 
was unfortunately too well illustrated by the case of P. B. attended by 
Surgeon Smyly, of Merrion square, and myself. The following notes 
were taken by Mr. Smyly — 

Case 3.— " Miss P. 13 , aged 20 ; of a full habit of body, in De- 
cember last was attacked with a very severe form of scarlatina. The 
eruption appeared on the 20th, and was very intense in its character ; in 
the progress of the complaint her head became much engaged, requiring 
the application of leeches; her throat also was very bad, to relieve which 
leeches were again applied. Considerable prostration of strength accom- 
panied the affection from the commencement. On the 30th, she was so 
far recovered that I took my leave. 

" It may be worthy of remark that her sister, who was first affected 
with the disease, had it so mildly that the nature of the affection was not 
discovered, nor did she require medical aid. 

"January 9, 1842 — I was again called to see Miss B , she then 

complained of a severe pain in her left side, which she first felt on going 
to bed, which became so violent during the night as to banish sleep. She 
had been till then going on as well as possible, recovering her strength 
daily, and was in excellent spirits. On the 8th, she eat heartily of beef- 
steaks for dinner, and drank some wine. I saw her sixteen hours after 
the commencement of the pain, when I found all the lower part of the 
left lung densely hepatized. 

" The treatment consisted in repeated cupping, attended each time 
with much relief. The exhibition of mercury so as to affect the mouth, 
antimonials, by all which means the acute symptoms disappeared, but no 
improvement took place in the condition of the lung. Her strength began 
to fail, and she died on the morning of the 9th of January, 1842. ,? 

In this case the most remarkable feature was the rapidity with which 
the lung was solidified, and the obstinate manner in which it refused to 
yield to treatment. 

The following case was also attended by Mr. Smyly and me, and to 
his eminent skill maybe attributed the recovery of the patient. It presents 
an unusual sequela of scarlatina, namely, aphthous ulceration of the anus, 
which, though not sufficiently pointed out in the late works on practice of 
medicine, was recognised and described by Huxham,and 1 introduce our 
case with Huxham's description, to show more clearly the identity of the 
two epidemics. 

After alluding to the profuse discharge that took place from ulcerated 
surfaces in the mouth and nostrils, he says — " A sudden stoppage of this 
rheum from the mouth and nostrils actually choaked several children ; 
and some swallowed such quantities of it, as occasioned excoriations of 
the intestines, violent gripings, dysentery, &c, nay even excoriations of 
the anus and buttocks. 17 * 

* Huxham on Fever, p. 2S0. London, 1772. 



448 CLINICAL MEDICINE. 

" Case 4. — Master James F., aged twelve, was affected with a very- 
severe form of scarlatina in July, 1841. The eruption began to appear 
the second day of his illness, and became very intense in its character, the 
whole surface of the skin being almost of a uniform redness. The ac- 
companying fever ran very high, demanding venesection to reduce it. 
The throat presented the usual appearances ; but in this case, the inflam- 
mation extended into the mouth, and we suspected, throughout the intes- 
tinal canal, indicated by the great irritability of the stomach and bowels, 
and the circumstance of the anus presenting the same aphthous appearance 
that the month did. The inflammation also extended into the left ear and 
caused the destructfon of the membrana tympani. In less than a month's 
time this young gentleman was so far recovered as to return to England, 
and has since enjoyed good health. " 

In the writings of Huxham and Fothergill, the reader will also find 
frequent allusions to cases where death was produced by uncontrollable 
epistaxis, during the epidemic of " sore throat" described by these authors. 
Thus Fothergill, after speaking of the usual mode of death in these cases, 
says, " Though this was the common progress of the disease where it 
terminated unhappily, yet it often varied from this type, ami was attended 
with very different symptoms. Some had an extreme difficulty of breath- 
ing almost from the first; some had a violent cough ; some were coma- 
tous ; others had a delirium ; some died in a lethargic stupor ; others bled 
to death at the nosey* The following is an example of this form of the 
disease : 

" Case 5. — I was called to see the Rev. Mr. C, aged 25, of regular 
temperate habits and healthy constitution. He was then labouring under 
severe fever with sore throat. On examining the fauces I found the tonsils 
extensively ulcerated. These were touched with nitrate of silver, and the 
next day they appeared much improved. On the third day of his illness 
an eruption appeared, neither too red nor too pale, in short as favourable 
as could be wished for, and perfectly normal as to its duration. During 
all this time the heat was intense ; and on the third day of the eruption, 
the cold affusion was employed, and was followed by marked relief; but 
the pulse still remained sharp and quick, never falling below 96. In this 
state he continued till the seventh day of his illness, when epistaxis oc- 
curred (to this he had been subject for a long time), and was followed by 
considerable relief of his head. The epistaxis was not excessive, and 
from the fact of its being habitual, excited but little alarm. About the 
thirteenth day the fever had almost gone : his sleep was good, and his 
tongue moist and clean. At this time a small tumour, situated at the 
angle of the left jaw, and which had been there from the beginning, was 
observed to enlarge. The next day it had spread considerably, was very 
red and painful. The fever increased, the tongue became dry, and his 
sleep was disturbed. On the sixteenth the tumour was examined and 
opened by Mr. Cusack. A large quantity of good healthy pus escaped, 
and the patient experienced great ease. On the eighteenth day a deeper 
incision was made by Mr. Cusack, and again a large quantity of good pus 
escaped ; but on this occasion no relief followed. On the next day the 
constitutional symptoms were much more severe; the epistaxis returned, 
and the tongue was now dry, black, and bleeding. There was no raving, 
nor was he at any time during his illness in the least delirious. 
* Fothergill's Works, vol. i., p. 353. London, 1783. 



SCARLATINA. 449 

"Notwithstanding that the nares were plugged, and every measure 
which Mr. Cusack and I could think of employed, the epistaxis continued, 
the bleeding from the tongue could not be arrested, the tumour in the 
neck became gangrenous, and on the twentieth day of his illness death 
terminated his sufferings." 

The next very interesting case was communicated to me by Professor 
Porter, so well known by his celebrated work on the " Pathology of the 
Larynx and Trachea ;" and as it illustrates another sequela of scarlatina, 
I shall lay it before the reader. There can be no doubt that the hemor- 
rhage originated in the way pointed out by Dr. Porter, and it shows in a 
convincing manner the assistance in diagnosis w T hich we derive from an 
accurate knowledge of anatomy. It will also be recollected, that this 
case differs in the manner in which the bleeding occurred from that men- 
tioned in the preceding pages by Dr. Geoghegan of Kildare. The older 
writers make frequent allusions to examples of this latter form of hemor- 
rhage. 

Professor Porter details the case in the following graphic manner: — 

" On or about the 18th of September, 1841, Master , aged eleven, 

was attacked w T ith scarlatina. He was of remarkably fair complexion, 
thin, almost transparent skin, and hair nearly white. The disease assumed 
rather a mild form, the eruption came out abundantly, and began to dis- 
appear about the evening of the fifth day. The throat was slightly en- 
gaged — very little difficulty in swallowing; but there were three or four 
external tumours, exactly resembling scrofulous glands, about to suppu- 
rate, and there was discharge of the puriform matter from both ears, with 
slight deafness of the left. 

41 At the end of about ten days he seemed to be progressing favourably 
as to health ; two of the little glands on the left side suppurated and were 
opened, discharging healthy pus; his appetite was pretty good and his 
sleep sufficient, but he always rested during the day, and remained awake 
at night. The discharge from the ears continued, and he had become 
quite deaf at the left side. 

" Soon after (I cannot be particular as to dates) a gland on the right 
side suppurated, and was opened. The discharge was healthy ; but that 
from the right ear began to be thin and abominably fetid, the smell evi- 
dently indicating its connection with some diseased bone. He was now 
totally deaf of both ears. Our communications with him were altogether 
by signs, and he was becoming paralytic of the right side of the face ; all 
his features being drawn frightfully to the opposite side when he either 
laughed or cried. At the end of about six weeks, however, he seemed 
in some respects to be greatly improved. He slept well, he was exceed- 
ingly cheerful and even lively, and his appetite almost voracious. He 
had so far recovered his hearing, that we could communicate easily with 
him ; but the foul discharge continued in great abundance from the right 
ear, and the paralysis of the face had increased. He continued appa- 
rently to improve in general health and even in strength until the end of 
the ninth week, and had occasionally been up and dressed for a few hours 
in the day, when in the middle of the night a new symptom appeared. 

" The child had been asleep, when he suddenly awoke, screamed out 

* Oh, my ear, my ear!' when almost instantly a gush of blood took place 

from the right ear. This blood w T as florid, and had the appearance of 

being arterial. It came gushing forth most profusely as if poured from 

30 



450 CLINICAL MEDICINE. 

the lip of a jug or ewer, and was sufficient in quantity to soil several 
towels before it ceased, which it did rather from the exhaustion of the 
patient than from the means employed to control it. I was not called 
during this first bleeding, but saw him early next morning. He com- 
plained of dreadful pain in the left side of the head, resembling hemicra- 
nia. The discharge from the ear was a thin fetid serum mixed with flakes 
of unhealthy matter and discoloured with blood ; and the paralysis of his 
face greatly increased, the features being distorted even when at rest. I 
attempted to plug the ear ; but the pressure interfering with the discharge 
of matter, caused intense pain, and could not be endured even for a few 
minutes. From this time he continued to bleed at irregular intervals 
until his death ; and as I was present on three or four occasions, I shall 
endeavour to describe one of the attacks of hemorrhage. 

" He seemed to have no previous warning whatever : sometimes the 
bleeding commenced during sleep, sometimes while he was amusing him- 
self with his toys. He generally gave a single scream at the instant, and 
then the blood burst forth with a gush that really astonished me. I never 
saw blood lost so rapidly in any surgical operation I ever witnessed, and 
only once in an accident where the deep jugular vein had been opened. 
This bleeding could hardly be controlled by pressure, and the attempt to 
do so caused intense pain, so that at times the nurse did not interfere, but 
allowed it to stop spontaneously, which it generally did in about a minute. 
The blood was always florid. The attacks occurred at irregular periods, 
and there never was hemorrhagic fever. 

" About a week before his death, I observed that the blood was begin- 
ning to make its way by the eustachian tube into the pharynx, some of 
which passed into the stomach, and some was expelled by the mouth, 
and then he bled sometimes by one passage, sometimes by the other, and 
occasionally by both. I need not say that he became pale, exsanguine, 
and exhausted, except to express surprise that any child of his age could 
have endured so long. The palate and inside of his mouth was as pale 
as any part of the external surface of his body. Exactly at the end of the 
thirteenth week from the commencement of his illness, he died after a 
slight gush of blood. 

" There was no post-mortem examination, and knowing the feelings of 
the child's parents I did not ask it ; therefore, the pathology of this case 
must be matter of conjecture. I think there can be no doubt that there 
was caries of some portion of the base of the skull, and from the symptoms, 
I always imagined it to be seated in the petrous portion of the temporal. 
The spot at which the carotid artery enters this bone is immediately adja- 
cent to the bony portion of the eustachian tube, and it is probable that this 
latter was the original seat of the disease, from which it spread, until it 
implicated the vessel. The extraordinary size of the stream satisfied me 
of its being furnished by some large vessel ; its colour showed it to be 
arterial ; its escape by the ear, and afterwards by the mouth and nose, 
proved its passage by the eustachian tube ; and I know of no vessel that 
would be sufficient to explain all the symptoms, unless the one I have men- 
tioned — the internal carotid." 

DR. OSBREy's ACCOUNT OF SCARLATINA OBSERVED AT ST. MARY'S DISPENSARY. 

" The number of cases of scarlet fever which were under my care from 
the close of the year 1840, the period at which that epidemic first ap- 



SCARLATINA. 451 

peared in my dispensary district, until its decline at the commencement 
of the present year, amounted to somewhat above two hundred. 

11 When it first appeared, the epidemic was of so mild a character, that 
I treated about forty cases without the occurrence of a single fatal one ; 
merely attending to the state of the bowels and secretions was sufficient 
to effect a cure. It soon, however, assumed a more formidable character. 
The cases which mostly proved fatal were those affected with diffuse 
inflammation of the neck ; they were generally children under four years 
of age. As it may be interesting, I shall describe to the best of my recol- 
lection the progress of that affection, together with the treatment which I 
found to be most successful. 

" Those cases of scarlatina in which this form of inflammation presented 
itself, I was usually not requested to attend until some time after its com- 
mencement, which generally took place at the decline of the eruption on 
the third or fourth day. The attending, or I may say secondary fever, 
was principally marked by the occurrence of cerebral and nervous symp- 
toms, the child either lay in a comatose state, or was excessively irritable 
and restless, and constantly whining. In those who were a few years 
older, a peculiar wildness of manner was occasionally observed, and if 
this were absent, the expression of the countenance was stupid and vacant. 
A common remark of their mother was, ' that they did not consider them 
in their right mind.' The children were affected with tremours of the ex- 
tremities ; the pulse was generally quick, and the tongue furred, but nei- 
ther invariably so. 

"The progress of the inflammation was very insidious, in most cases 
commencing as an indurated swelling behind the angle of the jaw on one 
side, which was at first very indolent, without any discoloration of the in- 
teguments, but as the affection advanced the swelling increased much more 
rapidly, often extending to the opposite side : the integuments then as- 
sumed a dusky red appearance, and became very tender to the touch; 
there was much edema, so that the part readily pitted when pressed by 
the finger, and there was an obscure sense of fluctuation communicated to 
the touch. In the advanced stage of the complaint, sensibility, which was 
previously great, diminished to such a degree that the child did not seem 
to suffer much pain if incisions were made into the swelling. When the 
patient survived till about the tenth day from the commencement of the 
affection, sloughs frequently formed, commencing in dark purple specks 
over the surface of the swelling, the sloughing rapidly spread, diarrhoea 
then set in; the abdomen became tympanitic ; spots of purpura at times 
appearing over the surface of the body, with the occurrence of passive he- 
morrhage from the mouth and bowels. The child either died comatose or 
exhausted by diarrhoea, in case dissolution was not quickened by the super- 
vention of sudden hemorrhage from some of the large vessels of the neck 
giving way in the sloughing. An attack of convulsions sometimes pre- 
ceded death, the period of which, unless when precipitated by exhausting 
treatment, to which it had been submitted previous to my seeing the child, 
varied from the seventh to the twenty-eighth day; the medium time being 
about the twelfth day from the commencement of the inflammation. 

"In those cases which fell under my observation I did not notice any 
thing differing from the common, either in the appearance or duration of 
the eruption, except that it was occasionally somewhat more faint than 
usual, and that the desquamation of the cuticle did not take place after its 



452 CLINICAL MEDICINE. 

disappearance. Though what I have just described was the usual pro- 
gress of inflammation when it ran a fatal course, yet sometimes it com- 
menced earlier, on the first or second day of the eruption, the fever being 
of a more inflammatory type, the skin being hot, pulse strong, tongue 
furred, and much thirst being present. 

"It is well known that this disposition to slough in scarlatina is not con- 
fined to diffuse inflammation of the neck, and that an inflammation of a 
similar character may attack other parts of the body — this was well exem- 
plified in two cases which were under my care — one that of a boy, aged 
six years, in whom scarlet fever immediately succeeded an attack of hoop- 
ing-cough, for the relief of which I had found it necessary to apply a blister 
to the chest, the other that of a fine child, his sister, aged four, who had 
received a slight scald in the ham of the left leg ; such portions of the 
vesicated surfaces which had not as yet healed, were attacked by the in- 
flammation, they were rapidly covered with ash-coloured sloughs, and the 
sloughing extended by livid margin. The boy, exhausted by the previous 
attack of hooping-cough, which had been unusually severe, I regret to say, 
died ; the little girl, who was more fortunate, recovered. The treatment, 
which was the same in both, consisted, locally, in the ulcers being kept 
constantly covered with fermenting poultices, and in the margins being 
occasionally touched with strong muriatic acid. The cautious exhibition 
of mild tonics, and of stimulants, both diffusible and permanent, carbonate 
of ammonia of course being used amongst the former, constituted the ge- 
neral treatment. Another case, which I considered very remarkable, fell 
under my observation, in which simultaneously with the gangrene of the 
neck, sloughs formed on both corneas, which rapidly extended, involving all 
the other textures of the eyes. This case struck me as being so interesting, 
that I brought my friend, Dr. Battersby, with me to see it. The destruc- 
tion of the eyes took place two days before dissolution. In each of these 
three cases the appearance of the part, when destroyed, closely resembled 
that of hospital gangrene. I did not notice any depots of purulent matter 
in the joints, or any other parts of the body, 

"Having now described the more formidable characters of the inflam- 
mation, I shall state the treatment which I found most efficacious in arrest- 
ing its progress, and in bringing about the more favourable terminations 
of resolution and abscess, and shall also take a short review of other modes 
of treatment that are occasionally resorted to. Mine simply consisted in 
the constant application of common oatmeal or linseed poultices, support- 
ing the child's strength by nourishing diet, and in the cautious exhibition 
of permanent and diffusible stimulants, carbonate of ammonia, as I have 
already said, being included in the latter. The practitioner should not I 
think swerve from this line of practice, though he may sometimes be urged 
by the parents, alarmed at the progress of the inflammation, to treat the 
child more actively, particularly with respect to the local applications. 
"When an abscess forms, the swelling previously diffused, becomes more 
prominent, soft, and fluctuating, there is no pitting on pressure with the 
finger, and the surface is usually of a rose red colour. Incisions may be 
then made to give exit to the matters. The symptoms of general disturb- 
ance, such as coma, convulsions, and such others as have been described 
in such cases disappear, tremours of the extremities alone remaining, and 
the child gradually recovers from the extreme debility from which it had 
hitherto suffered. I have said that stimulants should be given with much 



SCARLATINA. 453 

caution, for when used at all freely they are almost sure to induce convul- 
sions, to which there is a great tendency throughout the progress of the 
complaint. After the formation of abscess, however, they may be exhi- 
bited with greater boldness. In cases where there is much restlessness 
and irritability, or when diarrhoea has set in, which usually does not take 
place until the sloughing has commenced, I have given opiates, either in 
the form of Dover's powders, or the pulvis cretae c. opio, the doses being 
carefully graduated according to the age of the child. When the cases 
became complicated with purpura and passive hemorrhage, it is almost 
unnecessary for me to say, that I gave the mineral acids. 

" I have ordered chloride of soda both internally and as a lotion. 
Its internal exhibition did not appear to be productive of any benefit, 
but as a lotion and gargle it was highly useful in destroying fcetor. 
When I apprehended internal sloughing I occasionally touched the 
throat with muriatic acid lotions by means of a camel's-hair pencil or a 
piece of sponge. 

" Having had frequent opportunities of seeing the effects produced by 
the use of mercury, and also by local bleeding in the practice of others, I 
carefully avoided having recourse to such methods of treatment myself; 
the former, with rare exceptions, inducing purpura, passive hemorrhages, 
and sloughing, the accession of which is so much to be dreaded, and 
which are so liable to supervene of themselves. The latter precipitating 
dissolution by increasing the disposition to coma and collapse. I may 
here remark, that it is greatly to be deplored that many are so prone to 
submit young children to mercurial treatment in all cases which show any 
degree of obstinacy in resisting ordinary remedies without considering 
what possible object there may be in doing so, or what deleterious results 
are likely to accrue from it; and rarely have I observed such treatment fol- 
lowed by more woeful consequences than in the epidemic of scarlet fever 
in this city. Instances where mercury has been carelessly and indiscrimi- 
nately given to them for other complaints by practitioners, are frequently 
brought to my dispensary, in which most dreadful sloughingand dysentery- 
arose from its use. I do not by any means wish to impugn, by this 
remark, the plan proposed by Dr. Fitzpatrick, of submitting such children 
as have been exposed to the infection of scarlet fever, but have not as yet 
contracted it, to an alterative course of mercury, in order to prevent it 
assuming a malignant form in case they should take it (of this practice I 
have had myself no experience), nor do I mean to say that cases of scarlet 
fever may not at times become complicated with local diseases, as pleuritis, 
pneumonia, pericarditis, meningitis, and other affections in which the 
practitioner is imperatively called upon to order mercury. 

" I have made incisions myself into the swellings extending beneath 
the fascia of the neck, but I do not consider it good practice in the case 
of young children, however useful it may be in that of adults and of 
grown children, for the following reasons: when made in the early stage 
of the inflammation they have a tendency to prevent the occurrence of 
either of those most favourable results — resolution or abscess ; and when 
made in the advanced stages, unless when abscess or diffuse suppuration 
take place, they are of no use, they do not appear to check the sloughing 
of the integuments. The parents moreover to whose feelings such prac- 
tice is generally repugnant, are very apt to attribute whatever ill after- 
wards befals their child to these incisions having been made, a consiJe- 



454 CLINICAL MEDICINE. 

ration which I think should weigh with us in determining us against the 
practice, when no good is likely to arise from it. In case, however, 
abscess or diffuse suppuration of the cellular membrane occur we should 
not hesitate to make free openings. Diffuse suppuration of the cellular 
membrane, a result which I have only now alluded to, is almost as for- 
midable, w r hen the children are very young, as gangrene, inasmuch as 
they are scarcely ever able to bear up against the extensive suppuration, 
and consequently die of hectic. 

" Blisters and mustard cataplasms merely applied as rubefacients did 
not appear to me to be injurious, but I did not place much confidence 
in them. 

" It is obvious from what has been already observed, that we should 
be most cautious in making a prognosis when we meet this form of inflam- 
mation, as it often, when most mild at its commencement, subsequently 
runs a most fatal course, and when apparently of a most formidable 
character, terminates kindly. I have known many a practitioner, from 
mistaking its nature, supposing it to be nothing more than common scro- 
fulous inflammation, to augur favourably as to its termination, when its 
subsequent course showed how very erroneous such an opinion was. 
The constitutional symptoms, however, even though we have no very 
clear evidence of the child having had scarlet fever, will, when carefully 
attended to, always enable us to form a correct diagnosis of the disease. 
Perhaps it is not from recognising this disease, which is one of the most for- 
midable consequences of scarlet fever, that such discrepancies have 
occurred in the returns made by practitioners of the relative mortality of 
scarlatina in their practice. The children are frequently not brought to 
them until all traces of the eruption have disappeared, and in some cases, 
where it has been so faint as to have escaped the observation of the parents, 
or even that of the physician. In such cases it is easy to conceive that it 
might be mistaken for a disease sui generis, and that the previous existence 
of scarlatina might be entirely overlooked. 

" When sloughing of the integument has commenced, the chances of 
the child's recovery are greatly diminished, and when it is under a year 
old, it is, I think, almost hopeless. To have an opportunity of observing 
the sloughing stage, it is requisite that the child should survive some time. 
When death is precipitated by injudicious treatment, or if the child do 
not undergo any, dissolution occurs so early from the secondary fever, 
that no further local appearances than the more diffused swelling will be 
observed. I should here mention, that in the worst cases, there is no 
attempt at suppuration, and the part, when cut into, resembles somew T hat 
the cut surface of a rotten apple. 

" Even when resolution or abscess occurs, we must not be too hasty in 
giving a favourable prognosis ; for there is occasionally much subsequent 
debility, which may lead to a fatal result. 

" I have observed instances of this form of inflammation which suc- 
ceeded other exanthemata. The following case, which I received a note 
four weeks since to attend, at my dispensary, will prove, I think, an inte- 
resting example. It is that of a child aged two years, that had an attack 
of the natural small-pox ten days previous to my seeing it, and had been 
treated by another physician, who, on the occurrence of the inflammation 
of the neck (I understood from its mother), despaired of its recovery ; 
and, indeed, when I myself visited it, I had no better hopes. It was 



SCARLATINA. 455 

then lying in a state of coma, with its head quite motionless and thrown 
back, a large diffused swelling being behind the angle of each jaw and 
extending down the neck. The pulse was remarkably quick and weak, 
the tongue furred, abdomen tympanitic. On the child being submitted 
to the mode of treatment which I have described, it recovered from the 
state of coma it was in, and two very large abscesses formed in the situa- 
tion of the swellings, which I subsequently opened. The tympanitic state 
of the abdomen was relieved by injections of castor-oil and turpentine. 
When the sensibility and intelligence of the child returned, it was attacked 
with convulsions, consisting in constant motion of the extremities and 
twitchings of the face, which continued for two days. These convulsions 
I ascribed to debility, and treated as such. In this case purulent depots 
formed over the back of the hand and one foot ; also a large one over the 
scapula. The two former have been absorbed ; but as the one over the 
scapula still continues, and as there is no chance of its absorption, the 
recovery of the child is still doubtful. A few spots of purpura appeared 
in different parts of its body, and it has been frequently attacked with 
diarrhoea. Its mother states, that it was a strong child before the attack 
of small-pox. It is, however, apparently of scrofulous habit, and had 
once suffered from rickets. 

" Dr. Ford saw this case with me at different times, and had an oppor- 
tunity of observing the symptoms which I have described." 

My experience of the diffuse inflammation of the neck that follows 
scarlatina, accords with what has been stated by Dr. Osbrey ; and the 
recommendation to direct all our efforts to the support of the patient until 
the period of sloughing arrives, deserves the greatest attention. The fol- 
lowing case occurred a short time ago at the Meath Hospital : — A child 
four years old was admitted on the fourteenth day of its illness, with the 
integuments in the front of the neck in a state of gangrene. In a day or 
two the sloughs separated, leaving the muscles of the neck completely 
bare, and as distinct from each other as if dissected. The common caro- 
tids were also laid bare, and could be seen pulsating at the bottom of the 
ulcer. A few days after, granulations sprang up, and the ulcerated sur- 
face soon cicatrized. 1 have not been able to ascertain if any, or 
what amount of contraction of the neck followed the healing of the 
ulcer. 

Sir H. Marsh and I attended, not long since, a lady who had been 
affected for some days with fever and sore throat. She had no eruption 
on any part of her body ; but from the character of the fever, and the 
peculiar appearance of the throat, we suspected she was labouring under 
an attack of scarlatina. Her family were very anxious to ascertain the 
precise nature of her complaint ; and Ivisited her twice a-day for the first 
four or five days of her illness, carefully examining the skin at each visit, 
but could not discover the slightest trace of an efflorescence of any de- 
scription. She continued for several days to suffer from the fever and 
sore throat, and was at one time in a dangerous condition, but ultimately 
recovered by great care and the use of appropriate remedies. Xow I 
watched this case from the sixth hour after its commencement to its ter- 
mination, and repeatedly examined the skin, particularly that of the 
breast, abdomen, and inside of the knee and elbow-joints, places in which 
the eruption shows itself when it appears at all, but could not discover 
any vestige of it. You will often find a diffused redness about the knees 



456 CLINICAL MEDICINE. 

and elbows in cases where the eruption does not appear on any other part 
of the body ; but in this instance there was not the slightest deviation 
from the natural hue. Yet the result proved that it was scarlatina ; for 
the desquamation of the cuticle, which always attends this disease, took 
place, and the lady communicated the infection to several members of the 
family. A young gentleman residing in the house got a bad attack of 
scarlatina, two of the servants were also attacked, and the lady's father 
got sore throat ; in fact, there could be no doubt as to the nature of the 
disease. During her convalescence, she had desquamation of the cuticle ; 
and this is a point to which I would particularly call your attention. We 
are taught to look upon desquamation as the result of cutaneous affections 
of an inflammatory character: and it is an opinion very generally main- 
tained, that in scarlatina, as in psoriasis, the peeling off of the cuticle de- 
pends on the peculiar state of the skin produced by inflammation. It is 
stated, that the increased vascularity of the skin occasions a morbid secre- 
tion, and subsequent detachment of the epidermis, and that the same phe- 
nomenon is observed in all cutaneous affections of an inflammatory cha- 
racter. This may be generally, but not universally, true; for here we 
had an extensive desquamation of the cuticle without any eruption, with- 
out any previous redness, pain, or remarkable heat ; in fact, without any 
of the phenomena which are regarded as constituting inflammation. This 
seems to prove that there is something more than inflammation concerned 
as preparatory to that process which is termed desquamation, and that the 
change which the skin undergoes is not to be looked upon as a mere 
consequence of inflammation occupying the external surface of the 
corium. 

Another curious fact observed in this lady's case : since the attack which 
I have just described she has been shedding her nails ; that is to say, the 
nails of the fingers are all dropping off, and yet there is no appearance of 
inflammation of any kind about the hands to explain the occurrence. You 
are, of course, all aware that the dropping off of the nails is a species of 
desquamation. From the peculiar structure of the nail, and the mode in 
which it is formed in the matrix, it does not drop off at once like a scale 
of epidermis ; still I think we are authorised in looking upon the shedding 
of the nails as a species of desquamation. This affords a very curious 
subject for investigation, as connected with the history of fever. It is an 
opinion entertained by many persons, that desquamation of the skin takes 
place at a particular period of typhus ; and that this is not an occasional, 
or varying, but a constant and general phenomenon. This statement has 
been put forward most strongly by Dr. Perry, of Glasgow ; and he is also 
of opinion, that the period in which typhus is most contagious, is during 
the desquamation of the cuticle. It is also asserted, that scarlatina is 
more contagious during desquamation than at any other period of the dis- 
ease. This is at least the popular idea. How true it may be, my ex- 
perience or observation does not enable me to decide : nor am I prepared 
to offer any thing like an explanation of the occurrence. All I shall say 
on the present occasion is, that the occurrence of desquamation of the 
cuticle in typhus, and in cases of scarlatina without eruption, has greatly 
altered my ideas as totheconnectionbetweenitand cutaneous inflammation. 
I think, at least, that the process of desquamation in such cases is very 
different from inflammation, and that the morbid action of which desqua- 



SCARLATINA. 457 

mation is the result, has very little in common with the ordinary process 
of inflammation of the cutaneous surface. 

A gentleman who is in the habit of attending my lectures informs me 
that he has seen three cases of this form of scarlatina, characterized by the 
absence of the external efflorescence. They occurred in young persons, 
after puberty, and between the ages of fifteen and twenty-five. Each of 
these cases exhibited a considerable degree of fever, with increased quick- 
ness of pulse, thirst, heat of skin, diminution of the urinary secretion, and, 
after the first or second day, much depression, which continued for two 
or three days, and then yielded to treatment. The tongue was moist, but 
pointed, tremulous, red, and injected. The velum, isthmus faucium, 
tonsils, and upper part of the pharynx, were somewhat swollen, and of a 
very peculiar dark red colour, the redness being general, and equally 
diffused over the whole of the upper part of the pharynx as far as it could 
be examined. But the following case, which was very lately communi- 
cated to me by a practitioner of very great eminence in this city, is still 
more curious: Some years ago scarlatina broke out in this gentleman's 
family, and attacked all his children, with the exception of one young 
lady, who, although in constant attendance on her sisters during their 
illness, did not exhibit any symptoms whatsoever of the disease. When 
all the children had become convalescent, they were removed to the 
country for the benefit of air, whither she also accompanied them. Here 
she was, much to the astonishment of her family, attacked by the peculiar 
anasarca observed in persons who have recently laboured under scarlatina. 
Her father, under whose observation she had been during the whole time, 
was very much struck with the occurrence ; he paid particular attention 
to the case, and feels convinced that it was the result of latent scarlatina. 
This case, connected with those already detailed, is of great interest in a 
general pathological point of view. They appear to prove the fact, that 
in some instances diseases produced by contagion do not give rise to 
the w T hole train of phenomena by which they are ordinarily charac- 
terized. 

Let us turn for a moment to some of those diseases caused by the action 
of animal poisons on the system, as, for instance, measles. The symp- 
toms which generally attend and characterize measles are universally 
known. After an attack of fever, on the third or fourth day, coryza, 
sneezing, hoarseness, and cough, are complained of, and then a rash ap- 
pears, first on the face, and afterwards on the body and limbs. But it is 
not necessary that all these symptoms should appear, and that the sequence 
of morbid phenomena should be uninterrupted throughout ; on the con- 
trary, it frequently happens at particular periods, and in certain constitu- 
tions, that some of the most usual symptoms are scarcely observed, or 
altogether absent. You will find this point insisted on by Dr. Bateman, 
who has given a detailed description of a form of measles in w r hich the 
catarrhal symptoms are wanting, and which he has termed rubeola sine 
catarrho. The same remark applies to many other forms of disease. 
Thus we may have pneumonia without cough, and pleuritis without pain 
in the side. Those who have witnessed the course of the late epidemic 
cholera in this country, will recollect that many cases occurred in which 
vomiting, purging, or cramps were not observed. 

If we turn to fever, we find that the animal poison to which it owes its 
origin generally exhibits a certain number of symptoms, congregated 



458 CLINICAL MEDICINE. 

together, or observing a determined order and succession ; and these we 
meet with in most of the cases which come before us in practice. But 
we now and then see fever patients in whom one or more of the most 
prominent symptoms are absent. Thus occasionally there is no quick- 
ness of pulse or appearance of vascular excitement ; in some there are no 
cerebral symptoms ; in others no increase in the temperature of the skin. 
Indeed, I might go through the whole group of symptoms which accom- 
pany fever, and show that almost every one of them may be occasionally 
absent, and yet the fever of a severe and dangerous type. I recollect 
pointing out to the class last year the case of a man labouring under 
chronic enlargement of the spleen. He had been working for two or 
three seasons in some of the marshy districts of England, and had been 
occasionally ill, but never had symptoms of regular intermittent ; in fact, 
he had escaped the intermittent itself, but not what are usually deemed 
the consequences of it. We have been in the habit of explaining the 
enlargement of the spleen by referring it to the conflux of blood towards 
the internal organs, particularly the liver and spleen, during the cold 
stage of intermittent ; and we have endeavoured to explain the subcuta- 
neous edema which follows scarlatina, by attributing it to previous inflam- 
mation of the skin and subcutaneous cellular tissue; but the observations 
and facts which I have now brought forward will show that these opinions 
were founded on erroneous ideas. Turning to cases of chronic disease, 
we find in some, as for instance syphilis, that the poison taken into the 
system, gives rise in most cases to a determinate order of symptoms, e. g. 
bubo, sore throat, eruption on the skin, nodes, and syphilitic cachexy. 
Mr. Hunter has been at great pains in determining the order of the parts, 
and pointing out the tissues which are successively affected, and it is of 
considerable importance to have correct notions on this point ; but although 
the number and order of symptoms marked out by Mr. Hunter and others 
may be observed in most cases, they are not so in all ; and the same re- 
mark which has been made on the occasional absence of one or more im- 
portant symptoms, in scarlatina, will apply with equal force to syphilis. 
Now when this morbid poison which excites syphilis does not affect the 
constitution in such a manner as to occasion the production of all the 
symptoms which usually characterize this disease, and thus a variety of 
venereal is formed, which often proves a source of great embarrassment, 
not only to the young and inexperienced, but even to the senior members 
of the profession. 

It is of great consequence, in a practical point of view, to bear in 
mind the general proposition I have announced, viz., that in both acute 
and chronic diseases a constitutional affection may display its existence by 
only one or two of the numerous symptoms which usually accompany it : 
and this occurrence seems more frequent in the case of diseases produced 
by contagion and morbid animal or vegetable poisons, than in the case of 
maladies generated by causes developed in the system itself. 

The case of William Young, who was admitted on Wednesday last, 
has some claims to your attention, and demands a few observations on 
my part. This boy, who is about twelve years of age, had an attack of 
scarlatina some time ago, and had been dropsical for a week or ten days 
at the period of his admission. He was somewhat feverish, had thirst, 
heat of skin, and slight headache, cough, and difficulty of breathing, and 
on making an examination with the stethoscope, we detected numerous 



SCARLATINA. 459 

bronchial rales; his lower extremities were anasarcous, and he had some 
effusion into the peritoneal sac. We could not ascertain exactly the time 
when this train of symptoms commenced, but it is very probable that it 
was a week or ten days after the disappearance of scarlatina. When 
patients who have been recently labouring under an attack of scarlatina 
take cold, the anasarcous symptoms appear in a very short time after the 
attack ; but even where they are not exposed to cold, the dropsy appears 
generally about ten days or a fortnight after scarlatina, and is very often 
accompanied by some pectoral affection. The disease sets in with febrile 
exacerbations more or less marked; anasarca of the extremities is next 
noticed, and at the same time the patient has slight cough and difficulty 
of breathing, which generally proceeds from congestion of the bronchial 
mucous membrane, but may be the result (though less frequent) of pleuritis 
or pneumonia. 

If called to a case of this kind in the commencement, and where the 
patient is not greatly exhausted by previous disease, the treatment is ex- 
ceedingly simple. By opening a vein in the arm, and abstracting a quan- 
tity of blood proportioned to the age and strength of the patient, you 
remove the inflammatory state of the constitution, and arrest at once the 
anasarcous and pectoral symptoms. It may occasionally happen that active 
measures of this kind cannot be taken in consequence of the great debility 
of the patient from previous disease ; but, generally speaking, cases of 
anasarca after scarlatina bear antiphlogistic treatment well. It is not after 
cases of violent scarlatina, or where the patient's life has been in immi- 
nent danger, that the supervention of dropsy is most commonly observed ; 
the majority of dropsical cases of this kind are met with in patients who 
have had the disease mildly, and without any remarkable intensity 
either of the local or general' symptoms.* Hence, venesection is borne 
well, and its performance attended by the most decided good effects, 
particularly where the dropsy is complicated with pleuritis or pneu- 
monia. 

In the case before us, however, being uncertain as to the exact duration 
of the disease, and finding several symptoms present indicative of weak- 
ness, we were obliged to proceed with more caution. The boy had been 
ill a week, and appeared to be under the influence of digitalis administered 
before his admission, for his pulse was intermittent and wavering. Under 
these circumstances I determined to limit the antiphlogistic measures to 
the application of a few leeches over the abdomen. I did this with less 
hesitation, as an accurate examination of the chest showed that there was 
neither pleuritis nor pneumonia present. The internal remedies were 
calculated to increase the secretion from the kidneys. The boy's urine 
was remarkably albuminous, and of the specific gravity of 1027. This is 
a point worthy of remark. In many cases of dropsy after scarlatina, the 
urine is albuminous. Now, almost* every case of this kind will get well, 
and as convalescence progresses, you will observe that the urine ceases 
to be albuminous. These facts, of the truth of which I can speak with 
the fullest confidence, are quite sufficient to show that those persons are 
wrong who assert that albuminous urine is the result of organic disease of 
the kidneys. Albuminous urine is here, as Dr. Blackall observes, merely 
an indication of a peculiar inflammatory condition of the whole system, 

* The same remark is made by Dr. Tweedie, Cyc. Prac. Med., Vol. I. 



460 CLINICAL MEDICINE. 

and not of degeneration of the kidneys.* I may observe, however, that 
this is not always the case ; for I could point out examples where albu- 
minous urine is connected with an apparent opposite condition of the 
system ; in fact, a condition demanding the use of a generous diet and 
tonics. Hence, there must be great diversity in the treatment of dropsy 
with albuminous urine. Where it occurs after scarlatina, and is accom- 
panied by febrile symptoms, it is best treated by the lancet, nitre, purga- 
tives, and digitalis ; but where it occurs in chronic cases, without any 
remarkable excitement of the vascular system, without organic disease, 
and with more or less debility, it requires to be treated with tonics, gene- 
rous diet, and full doses of opium. In the present case I only applied a 
few leeches to the belly, and kept the bow T els gently open for the first few 
days, being determined to wait until the pulse became regular before 1 
ventured on any decided plan of treatment. I then ordered mercurial 
frictions to the abdomen and axillae, and gave mercury internally combined 
with small quantities of digitalis. He also got a draught twice a-day 
composed of carbonate of soda, tincture of squill, and syrup of orange 
peel. These remedies we shall continue for some time, carefully watching 
their effects. 

From the state of weakness this boy was in at the period of his admis- 
sion, and the length of time the disease has lasted, I have not thought it 
advisable to bleed him. When cases of this kind become chronic, they 
are very difficult of cure, and require very delicate management. You 
will frequently have to run through the whole list of remedies employed 
on such occasions, before you can hit on one that proves successful. I 
recollect a case of this kind, in which the anasarca was extreme, and the 
boy's legs were enormously swollen ; the dropsy was accompanied by 
scanty secretion of urine, but without any distinct febrile excitement. 
After having used every remedy I could think of, for nearly three months, 
without any benefit, I resolved to try the effects of cold affusion, from 
which I had experienced much advantage some time previously in another 
case. I ordered a large vessel filled with pump water, in which a quan- 
tity of salt had been dissolved, to be poured over him twice a-day, for 
the space of tw T o or three minutes each time, immediately after which the 
boy was wiped perfectly dry and put to bed. The good effects of this 
measure became soon evident ; a copious discharge of urine took place, 
the swelling of the limbs subsided, and in six or seven days the child was 
able to run about as usual. * * * * 

This case went on unfavourably, and the boy died, after lingering 
several weeks, in a state of extreme dropsical swelling and great suffering, 
distension, and dyspnoea. As his urine continued highly albuminous 
throughout, we were excessively curious to learn "what was the condition 
of his kidneys. The post-mortem examination was made a few hours 
after death, and the kidneys w T ere found in every respect healthy ; their 
size, shape, consistence, and colour, were perfectly normal. So striking 
an exception to the general rule ought to shake the confidence of those 
who assert that albuminous urine results from Bright's kidney. The 
long-continued presence of albuminous urine, in a case where no such 
state of kidney existed, forms conclusive evidence that this state of urine 

* These opinions have been since advocated by Dr. Burrowes, in his admirable essay on 
Scarlatina, published in the " Library of Medicine" Vol. I., and which 1 feel great pleasure 
in recommending to the attention of my readers. 



SCARLATINA. 461 

is not necessarily the result of that renal degeneration to which it is referred 
by Dr. Bright; the occurrence of one positive exception is sufficient to 
disprove such a conclusion, even though supported by a thousand cases, 
and, consequently, when albuminous urine in chronic dropsy is found to 
occur along with Bright's kidney, I consider this particular state of urine 
and of kidney, as depending upon different causes, which often co-exist 
in chronic dropsy, and consequently I regard albuminous urine as a sign 
o^Bright's kidney, but not as its result.* 

It has been already observed that anasarca seldom occurs after severe 
and dangerous scarlatina, but it is not unfrequent as a sequela of the very 
mildest forms of that disease ; a fact of which every practitioner should 
be aware, and a knowledge of which should prevent us from pronouncing 
a patient out of danger until the period during which dropsy may super- 
vene, is passed. To impress the necessity of caution, I may mention that 
I have seen several cases of scarlatina in young persons and children so 
mild as not to require confinement to bed, and yet followed about the 
18th or 20th day, by anasarca ; this usually yields to treatment without 
much trouble, but in some patients, without our being able to assign any 
cause for it, the anasarca increases rapidly, the pulse rises, and in a few 
days is excessively rapid, from 130 to 150, becoming hourly weaker and 
weaker while the heart's action is strong and tumultuous ; the skin is hot, 
and in many individuals inflammatory symptoms manifest themselves in 
the head, chest, or belly, and the patient is carried off by internal inflam- 
matory effusion into one or other of these cavities. Other cases are more 
treacherous, and the approach of danger is not indicated by anything but 
the rising of the pulse, and the rapid increase of the dropsical effusion, 
soon to be followed by convulsions, that succeed each other until death 
closes the scene, a termination so much the more unexpected, as these 
cerebral symptoms have not been preceded by the least headache, or any 
perceptible affection of the functions of the brain ! 

In addition to the remedies already mentioned, I can speak with the 
greatest confidence of the utility of hydriodate of potash in the form of 
anasarca we are now treating of; and i may add, that I have found the fol- 
lowing line of treatment more successful than any other in the malignant 
forms of scarlatina — local bleeding by leeches when necessary ; wine and 
carbonate of ammonia freely given with camphor-mixture. In some cases 
attended with intense heat of the skin, the cold affusion has given great 
relief, in others it has failed. 

* In another part of this work, the reader will find more extended observations on this 
subject. 



462 CLINICAL MEDICINE. 



LECTURE XXXVII. 



I adverted in the foregoing lectures to the subject of influenza, and en- 
deavoured to point out some of the principal features in which epidemics 
differ, as to their mode of spreading, from diseases which owe their dif- 
fusion chiefly to contagion. I stated that contagious disorders were com- 
paratively slow in their progress, attacking different masses of the popu- 
lation in succession, and exhibiting, in general, a tendency to affect dis- 
tinct classes of the community at different periods. On the other hand, 
when an epidemic like influenza makes its appearance, every thing comes 
under its influence almost simultaneously, and it overshadows the whole 
country in the space of a few weeks. Such is the course of the present 
epidemic, and so it was with the influenza of 1782, which travelled from 
the east, and left traces of its ravages in almost every quarter of the globe. 
In the case of epidemics which traverse the whole, or nearly the whole 
extent of the inhabited portion of the earth, it would be a matter of great 
interest to ascertain the place of their first appearance, or their point of 
departure. The cholera commenced in Hindostan, and in its route fol- 
lowed the great lines of communication and commerce : its general pro- 
gress has been north-west ; but in Portugal, Spain, and Italy, it has tra- 
velled in various directions, its progress, however, being in general along 
the great lines of communication leading from the part of the frontier 
w T here it first broke out, towards the large towns in the interior. It is 
probable that influenza pursues some certain and uniform course, inde- 
pendent of the physical circumstances which retarded, accelerated, or 
stopped the progress of Asiatic cholera. It is likely, too, that its rate of 
spreading is subject to fewer variations. Cholera took years to accom- 
plish its journey from Hindostan to Britain ; but, once established there, 
it crossed the Atlantic at a single step. The march of influenza has not 
as yet been mapped out, but, from the accounts which have reached us, 
it seems to have travelled at the same time in very different directions, 
arriving at Cape Town in January, during mid-summer, and in London 
in the same month, during mid-winter ; while it is reported to have 
reached New Holland, and to have raged among our antipodes, two 
months earlier. 

It is obvious that influenza does not depend upon mere variations of 
temperature, for we have had many seasons as changeable as the present, 
without the occurrence of any such epidemic. Besides, influenza is known 
to be a disease which travels through the most different climates, preserv- 
ing its peculiar character and identity in all. It is not to be supposed 
that the same temperature, or the same barometrical and hygrometrical 
conditions of the atmosphere, prevail here as in Spain, France, Germany, 
or Sweden : yet in all these countries the present influenza has exhibited 

* These lectures were delivered durin? the session of 1836-7. 



INFLUENZA. 463 

an uniformity of character, and an identity of type, proving beyond all 
doubt that it is one and the same disease. That influenza is not produced 
by a low temperature, is proved by the occurrence of the disease in the 
month of June, in the epidemic of 1762 ; and in the months of May and 
June, in that of 1782 ; as well as by its appearance at the Cape of Good 
Hope in the middle of summer, as I have already noticed. At present 
influenza is rather on the increase in this city ; and yet you have observed 
that, for the last week, the weather has been remarkable for its serenity 
and agreeable mildness. In London, many were led, by a limited view 
of the subject, to consider its origin as connected with the breaking up of 
the frost, and the peculiar state of atmosphere attending a general thaw. 
Influenza is not influenced in its progress by situation or locality ; it 
does not creep along the shores, or follow the course of large rivers, 
or select low, marshy districts, in preference to drier and more elevated 
soils. 

From what has been said, it is obvious that influenza does not depend 
upon vicissitudes of temperature, peculiarities of situation, or supposed 
moist or dry states of the atmosphere ; neither does it arise from the pre- 
valence of certain winds, for meteorological observation furnishes many 
instances of the prevalence of such winds without any influenza ; and, on 
the other hand, it frequently travels against the wind.* It is probable 
that influenza may depend chiefly on telluric influence — upon some agency 
connected with variations in the physical conditions which operate on the 
external surface of our planet ; but on this point we can only speak con- 
jecturally, in the present state of our knowledge, and we should not allow 
ourselves to lapse into mere speculative and fruitless disquisitions. How 
often the variations to which I have alluded occur, and whether they are 
subject to any general law, remains yet to be determined. Several epi- 
demics of this description have been distinctly recorded in the eighteenth 
century, viz., in 1708, 1712, 1729, 17 32, 1742, 1762, 1767, 1775, 1782, 
1789 ; while in the portion of the nineteenth century already elapsed, four 
influenzas have occurred, viz., in 1803, 1831, 1834, and 1837. This 
list is as complete as our medical annals will permit us to make it, but 
still we cannot rely on it as including all the epidemics of this nature 
which have occurred during the last one hundred and thirty-seven years. 
Supposing it correct, it would indicate the average return of influenza 
once every ten years. In making calculations of this kind, medical 
writers should always take care not to confound influenza, or disease 

* The same views were advocated by the late Dr. Holland, since the above lecture was 
delivered, at p. 195 of his " Medical Notes and Reflections," he says, "It is true that some 
authors, and in concurrence with common opinion, have attributed these epidemics solely to 
atmospheric changes, and the influence of extraordinary seasons upon the human body. And 
it must be admitted, on behalf of this opinion, that certain of the seasons during which they 
have prevailed, have been remarkable and anomalous ; and further, that in common catarrh 
from obvious causes of atmospheric change, many of the symptoms resemble the lighter and 
more transient forms of the disorder in question. But there is something manifestly beyond 
this relation and independent of it. A disease which has appeared and spread at different 
seasons, in the middle of summer as well as in the depth of winter ; which has been found 
traversing whole continents, continuing their course through many successive months, and 
often assuming even a definite direction of progress, which affects contiguous places in different 
degrees, and at different times; which frequently continues in the same place for several weeks 
or months, under every appreciable variety of atmospheric state; and which often affects, 
almost simultaneously, large masses of people living on the same spot, while others in adjoining 
localities are exempt ; such disease cannot be considered as due to any of the known qualities 
or variations of the atmosphere, to which the term weather is applied." 



464 CLINICAL MEDICINE. 

which spreads rapidly over the whole globe, regardless of season and 
climate, with those local catarrhal affections that occur in all temperate 
climates almost annually. One thing, at least, is certain with respect to 
this disease, that it does not arise from exposure to cold, or, as it is termed, 
from catching cold. This I have repeatedly observed. Persons who took 
the best care of themselves, who always went warmly clothed, and were 
never exposed to the inclemency of the weather, took the disease just as 
readily as the half-clad labourer, who had to undergo daily exposure to 
all the vicissitudes of our changeful climate. But it should be observed 
that, although the attack of influenza in any individual was not necessa- 
rily dependent on exposure to cold, yet in many instances it was evident 
that catching cold determined the immediate access of influenza, or 
increased its violence when present. 

I have also observed, that it seldom attacked persons labouring under 
acute diseases, until the period of convalescence arrived, when their immu- 
nity ceased, and they became just as liable to its invasion as others. Thus, 
patients labouring under typhus escaped as long as the fever continued ; 
but frequently, on the very day the crisis occurred, and symptoms of 
returning convalescence appeared, they were seized with influenza. This 
is a very unfortunate circumstance. Just as a patient had struggled 
through a fever of seventeen, nineteen, or twenty-one days, he was 
attacked with a new and dangerous malady, which again placed him in 
a situation of imminent danger. 

You must have observed, that influenza does not appear in every indi- 
vidual with the same violence, or exhibit in all, symptoms identical in 
their intensity or duration. As in most other epidemics which affect 
society at large, the different constitutions and ages of the individuals, 
and the different states in which the morbid influence finds them, modify 
greatly the nature of the attack ; so that, although a vast number are 
affected, they suffer in very different degrees, and the complaint exhibits 
every variety of shade, from simple coryza, or catarrh, requiring no treat- 
ment, to catarrhal fever of the worst and most unmanageable description. 
Many persons laboured under what would be termed a common cold, 
were it not from the extreme frequency of such symptoms, combined with 
other circumstances which mark the nature of the disease. The same 
thing was observed with respect to cholera : few persons, (luring the pre- 
valence of cholera, escaped without undergoing some form of bowel 
attack, but the mode and character of such attacks vary very remarkably. 

Influenza is not by any means so severe or so rapidly fatal a disease as 
cholera, but the mortality which it has produced is greater, as it affects 
almost every person in society, while the ravages of cholera were compa- 
ratively limited. Consequently, although the proportion of deaths among 
a given number of individuals attacked was greater in cholera, the mor- 
tality for society at large is much greater in influenza. In Dublin, it is 
extremely difficult to obtain any thing like exact statistical details of the 
comparative mortality at different periods, for no general registry of deaths 
is kept in this city. Through the kindness of Mr. Eiffle, late Secretary to 
the Caledonian Insurance Company, I have been enabled to get an accu- 
rate return of the interments in Prospect Cemetery, at Glasnevin, in the 
suburbs of this city, for the months of January and February, during which 
influenza was very prevalent, as also for the corresponding months of the 



INFLUENZA. 465 

preceding year. He has also furnished me with an account of the burials 
during the months before and after influenza. 

Interments at Prospect Cemetery, Glasnevin ; probably the largest in 

Ireland. 

In December, 1835 . . 355 In December, 1836 . . 413 

January, 1836 . . 392 January, 1837 . . 821 

February, 1836 . . 362 February, 1837 . . 537 

March, 1836 . . 392 March, 1837 . . 477 

Total for four months, 1501 2248 

1501 

Increase during Influenza, 747 

Assuming, then, that in Prospect Cemetery alone, about seven hundred 
persons are buried who died of influenza, and that there are at least three 
times as many persons buried in the other church-yards of the city and 
suburbs, we may conclude that in Dublin alone more than four thousand 
people died of the influenza, not taking into account the greater number 
who, although they got over the immediate attack of the epidemic, sank 
afterwards under various diseases, of which influenza had laid the foun- 
dation. In Paris, the influenza caused likewise a great mortality ; for it 
appears, from a statement in the R6vue Medicale, that the average daily 
mortality, during the first fifteen days of February, amounted to one hun- 
dred and ten, which is more than double the usual average. This only 
refers to persons dying in their own houses, and does not include the 
deaths in the hospitals. Eighteen thousand die in private houses annually' 
in Paris — i. e. on an average about fifty daily. The rate varies from 
twenty to seventy a-day, according to the season ; but during the first 
fifteen days of February, it rose from fifty-eight to one hundred and fifty- 
two in the day. 

Influenza has been very fatal where it attacked persons who had been 
subject to chronic bronchitis, or who had happened to labour under any 
form of asthmatic affection ; for this, I confess, I was not quite prepared. 
And when first called to attend asthmatic persons labouring under influ- 
enza, I expected that, from being accustomed to periodic attacks of dys- 
pnoea and cough, they would be better qualified to bear the disease, and 
would continue to exhibit that tenacity of life for which asthmatic persons 
are so remarkable. The old also suffered considerably; but some very 
old persons had extremely severe attacks of influenza, and yet escaped. 
I attended, along with Mr. Maurice Collis, the venerable Judge Day, the 
contemporary of Goldsmith, who, at the age of ninety-three, had sufficient 
strength of constitution to shake off a most violent seizure. Two gentle- 
men, who had fought at the battle of Bunker's Hill, also survived the 
disease in a severe form ; but generally speaking, it was very fatal among 
the aged. Influenza was also very fatal among persons who laboured 
under disease of the heart ; and in this instance age made no difference 
as to result, for the young and old were equally liable to danger. I have 
also seen it fatal in cases of deformity of the chest, from curvature of the 
spine, and other causes. The mortality was also very great among per- 
sons in advanced life who laboured under tussis senilis : in a word, all 
31 



466 CLINICAL MEDICINE. 

persons labouring under pulmonary irritation, or weakness, were exposed 
to very considerable danger. Subsequent experience has proved also, 
that where influenza left behind an obstinate and irritating cough, and 
where the constitution had a scrofulous taint, the disease was very apt to 
pass into tubercular phthisis. Among all the families I know, but two 
escaped the influenza altogether: one consisted of eleven children, be- 
sides the parents and servants, and resided in Pill Lane, in the very cen- 
tre of the city ; the other family consisted of five females, advanced in 
life, and who lived in one of the fashionable streets. 

Allow me to digress here for a moment, for the purpose of making one 
observation, which a review of several cases of influenza, attended with 
severe pulmonary symptoms, suggests to me. It is a common error in 
pathology to confound effects with causes, and where the cause of a dis- 
ease is not, and probably cannot be known, to fix on some peculiar and 
leading symptom, and attribute to it the origin of all the rest. But it is 
quite illogical to say that one symptom is the cause of another, or that 
because it has the precedence, it should also have the initiative. I 
alluded to this error in a former lecture, when speaking on the pathology 
of scarlatina. It has been over and over again asserted, that the dropsy 
of scarlatina arises from the previous inflammatory affection of the skin, or 
subcutaneous tissues ; and the same thing has been asserted with regard 
to the desquamation of the cuticle. But I have brought forward facts and 
arguments to prove that this opinion is not founded in truth, and that 
dropsy, as well as desquamation of the cuticle, may take place where there 
has been no eruption whatever, and not the least trace of cutaneous 
or subcutaneous inflammation. Now when a person, after exposure to 
cold, gets pneumonia or bronchitis, followed by anasarca, it is quite a 
common thing to hear it said, that the anasarca had its origin in the pul- 
monary affection, and that the effusion of serum depended on obstructed 
transmission of blood through the lung. The same mode of explanation 
has been applied to disease of the heart as the cause of dropsy. This 
explanation, however, appears to me inadequate and unsatisfactory. Many 
cases of influenza were accompanied by extreme congestion of the lungs, 
and consequently imperfect aeration of the blood ; and yet I have not in 
a single instance noticed the occurrence of dropsy as an immediate or re- 
mote consequence. Were dropsy dependent on the state of the lung to 
which I have alluded, it would have shown itself in some cases at least ; 
and yet I have seen individuals attacked with influenza labouring under 
orthopncea and severe pulmonary symptoms for weeks, without observing, 
in any instance, the slightest anasarca or edema.* This has strongly 
impressed upon my mind the conviction, that when dropsy comes on after 
disease of the lung, that the one is not always the consequence of the 
other, but that both often result from the same cause, and owe their origin 
to the same morbid impression on the system. This error has been fur- 
ther confirmed by the results of treatment, practitioners having found that 
measures adapted to remove congestion of the lung tended also to remove 
the dropsy ; forgetting here, that where two symptoms closely allied to- 
gether arise from the same cause, you will be most likely to relieve both 
by those means which are effectual in removing either. The principles 

* I saw one old gentleman at Rathmines, whose feet and legs were much swollen ; but 
this I attributed to bis having remained so many days and nights in his chair, unable to lie 
down. 



INFLUENZA. 467 

which I have here briefly alluded to, will apply to many other combina- 
tions of disease ; it is one of general application, and, in my mind, of no 
ordinary importance. 

The present epidemic differs in many points from that which prevailed 
here about three years ago. The influenza of 1833-4 was by no means 
so generally fatal as the present. It was characterized, like the present, 
by considerable irritation of the tracheal and bronchial mucous membrane, 
but not by the severe bronchitis and pneumonia which have been witnessed 
in many cases of the present disease. The former raged in Dublin chiefly 
during the months of March and April. It came on very suddenly, with 
rapid pulse, hot skin, great prostration, languor, and excessive sweating; 
there was cough, coryza, and not unfrequently, vomiting at the commence- 
ment. One of the most prominent symptoms, however, was headache, 
which was excessively severe. There was also, cccteris paribus, more de- 
bility, and the patients did not bear bleeding so well as they have done 
at present. But the most material point in which they differ is the com- 
parative mortality. The disease in 1834 carried off some very suddenly 
with cerebral symptoms, and proved fatal to others from oppression of the 
chest and dyspnoea. Few, however, died, who survived for a week after 
they had been attacked, and the disease rarely left behind it a cough at 
all approaching in violence and obstinacy to that which now harasses con- 
valescents. On the whole, the fever accompanying the influenza of 1834 
was more acute, and set in with more marked depression of the nervous 
system, than that which attends the present, and the disease was much 
less liable to become chronic. 

It would conduce greatly to the advantage of medical science, if a 
brief and accurate history was left to posterity of the character, symptoms, 
pathological phenomena, and treatment of every epidemic. Such a record 
would prove a guide and beacon to the practitioners of future ages — 
would enable them to draw important comparisons between the existing 
and the past — and thus arrive at a more fixed and available knowledge 
of the nature and habits of epidemic complaints. 

There are, I have no doubt, many curious forms of epidemic disease 
which pass through society either wholly unnoticed, or confounded with 
others to which they have some slight affinity. I think I have seen par- 
ticular forms of scarlatina, measles, small-pox, and fever, which have not 
been accurately noted, although they prevailed as epidemics. If every 
form of epidemic was noted, and the order of its succession marked, it 
would remain to be ascertained by posterity whether there may not be 
what may be termed cycles of epidemics, and whether disease, after 
having manifested itself in determinate forms, following each other in 
determinate succession, may not commence again after the lapse of a cer- 
tain number of years, and pursue the same course. This is not impossible, 
if we suppose that epidemics are connected with telluric or electrical in- 
fluences, which are now known to observe a periodic course. Were this 
ascertained, a sort of observatory of epidemics could be easily established 
in the various civilized states. 

In treating of the nature of the present influenza, it will be proper to 
consider, in the first place, the general constitutional symptoms which 
attend it, and afterwards glance at those which are chiefly of a local 
description. In some cases of influenza, there is little or no fever ; 



468 CLINICAL MEDICINE. 

neither does the presence of fever seem essential to the more severe 
or even fatal cases, although, generally speaking, fever occupies a 
very prominent position among the group of symptoms by which the 
disease is characterized. I have seen cases in which there was no- 
thinglike regular fever from beginning to end, and yet which terminated 
fatally. 

I am at present treating two patients who have been labouring under 
orthopncea for the last ten days, and yet in these patients the skin is cool, 
the pulse in general soft, and very little above the normal standard, and 
the tongue, though furred, quite moist; yet so great is the distress of respi- 
ration, that they are obliged to remain sitting up in bed night and day, 
panting for breath; and I am of opinion that both will die. This, how- 
ever, is the exception with respect to severe cases, the majority being at- 
tended with very considerable fever. In the slight cases the fever is 
scarcely perceived, or altogether absent; this was the case with myself 
and some of my friends. We have coryza, hoarseness, cough, and some 
degree of pulmonary irritation, without any fever. At first, I thought 
that fever was an essential part of the disease ; but the cases to which I 
have alluded, and others of a similar kind, have convinced me that this 
is not the fact. Where the fever appears, it comes on with the usual 
symptoms of pyrexia — namely, sense of chilliness, particularly about the 
small of the back, without decided rigors, flying pains in the limbs and 
joints, and headache, generally referred to the situation of the frontal sinus. 
There is from the commencement, great restlessness, jactitation, and more 
or less insomnia. Sickness of the stomach, loss of appetite, and tendency 
to diarrhoea, are also common symptoms. The skin is in general hot, and 
without any tendency to moisture, although, in some cases, there are oc- 
casional perspirations. These, however, are seldom general or regular, 
and last only for a few hours. The pulse is accelerated and tolerably full, 
occasionally even hard and wiry. These symptoms are very subject to 
slight exacerbations and remissions, and seldom continue the same for 
more than twelve hours together. Where the disease exists for any length 
of time in a violent form, the tongue usually becomes furred and loaded, 
the patient loses all relish for food, and in many cases complains of ha- 
rassing thirst. In severe cases, the most prominent symptoms are, cough, 
wheezing, restlessness, dyspnoea, and loss of sleep. The appetite is gen- 
erally more or less impaired ; but I have seen some severe cases in which 
it did not fail remarkably for several days ; the restlessness and jactita- 
tion attend many cases throughout. You are not, however, to suppose, 
that this always depends on the presence of pain or fever. The head- 
ache is not in all severe or distressing; and I have already stated, that 
the fever is not so general or so violent as one would suppose. The loss 
of sleep depends upon derangement in the tone of the nervous system, 
independent of fever ; for I have observed it in numerous patients, in 
whom scarcely any febrile excitement was observable; but when com- 
plicated with fever, both react upon and aggravate each other. The skin, 
where fever is present, is hot : this heat is interrupted by occasional per- 
spirations, which, however, do not give much relief, or tend to diminish 
the amount of increased temperature. Sometimes the skin is hot, and at 
the same time bedewed with perspiration during the whole course of the 
disease ; but this is rather unusual. The pulse is seldom the same through- 
out; one time you will find it quick and rather hard; in six hours after- 



INFLUENZA. 469 

wards it will be quick and soft; in six or eight hours more it will appear 
as if about to fall to the normal standard ; and next day you will find it 
quick and jerking again. These changes are accompanied by corre- 
sponding alterations in the temperature and humidity of the skin. But 
what is most remarkable with regard to the pulse is, that it sometimes 
becomes full, and rather strong and wiry towards the termination of the 
disease ; and this you will observe in patients who have been suffering 
for days, or even weeks. I have been attending for the last fortnight, 
with Mr. Colles, a gentleman in Castle-street, aged sixty, of a full habit, 
and subject to attacks of dyspnoea and cough during winter. This gen- 
tleman was attacked with influenza, ushered in and accompanied by severe 
fever; and it was observed, that as the disease advanced, his pulse became 
fuller and stronger, so that it was thought advisable to bleed him. He 
was bled with apparent relief, and the blood was extensively buffed and 
cupped. .This phenomenon I have observed in every case attended with 
fever, and indeed in some where no appreciable fever existed. Thus, a 
gentleman in Dame-street, who had no fever, and who merely laboured 
under teazing cough, distress of respiration, and oppression of the chest, 
the blood, on being drawn, exhibited very distinct buffing and cupping. 
The same thing happened in the case of a gentleman, in Dominick-street, 
whom I ordered to be blooded under exactly the same circumstances. 
The gentleman in Castle-street, whom I attended with Mr. Colles, ex- 
hibited a very curious state of pulse. In him, as in many others, the 
pulse was extremely variable as to its strength, being at one time hard 
and firm, and at another soft and weak. If you were to visit him in the 
morning, from the feel of the pulse you would be inclined to give him 
stimulants; if you saw him for the first time on the evening of the same 
day, you would think venesection indispensable. This gentleman's state 
was hopeless; he laboured under great suffering, dyspnoea, and inability 
to cough up the viscid mucous secretion, and yet his pulse was both strong 
and firm. Mr. Colles, whose attention I directed to the state of the pulse, 
observed, that were he to feel it without seeing the patient, or knowing his 
previous history, he would be greatly inclined to bleed him immediately. 
I have adverted in a former lecture to this state of the pulse, as connected 
with irritation of the nervous system, rather than with any inflammatory 
state of the constitution in general ; and, therefore, I shall not now recur 
to the subject further, than to remark, that I have never observed any 
disease in which the pulse formed so bad a guide as to the propriety of 
venesection, as the present epidemic, in some cases, venesection was 
most useful, although the pulse was in every respect natural ; in others, 
it could not be borne even to the smallest amount, although the pulse 
was hard and wiry. Neither was the state of the blood an unerr- 
ing guide; for even in those who sank rapidly, from the debilitating 
effects of moderate bleeding, the blood was very much cupped and 
buffed.* 

* " The most important question," says Dr. HoiXAxn, " in the treatment in influenza doubt- 
less regards the extent to which antiphlogistic means may be carried, or the fitness of employ- 
ing them at all. And the point as to bleeding is that which stands foremost here, and has 
chiefly embarrassed all practitioners. The most general precept on this subject is liable to 
exceptions; but collecting what on the whole is safest and most expedient, it must be one 
which forbids bleeding as an ordinary practice in this disorder. The adynamic type through- 
out in the greater number of cases; the singular disproportion in all hetween the seeming 
severit, of the inflammatory symptoms and their real slightness or nullity ; the actual failure 



470 CLINICAL MEDICINE. 

Before I conclude, I shall mention the particulars of a very remarkable 
case which came recently under my notice. I was called to visit a lady, 
somewhat advanced in life, but of a good constitution, and labouring under 
the ordinary form of influenza, with considerable dyspnoea and cough. In 
the course of eight or nine days her symptoms began to decline ; she got 
up, and seemed convalescent. As the cough and pulmonary irritation still 
prevailed to a certain extent, it was thought advisable not to allow her to 
eat meat, but she obtained leave to take some fresh haddock. After din- 
ner, her cough becoming more troublesome than before, she had frequent 
recourse to a stale and rancid cough-bottle, containing squill and ipecacu- 
anha. During the evening and night she felt her dinner like an undi- 
gested load, and her stomach turned. She vomited, and was purged and 
griped incessantly, until I saw her next day. On the third day, the medi- 
cines I had ordered moderated the purging, but the nausea and occasional 
vomiting continued. On the fourth day, the purging had entirely ceased, 
but the sickness of stomach persisted. I sought to appease this by the 
ordinary means, which failing, I examined her with care on the following 
day, and discovered a strangulated hernia. At this time the pulse had 
scarcely risen above the natural standard. Mr. Cusack operated that 
night with his usual skill, and all the symptoms depending on incarce- 
rated hernia ceased. But they had scarcely disappeared, when the pul- 
monary symptoms and the copious secretion from the bronchial tubes 
recurred, and she did not survive this relapse of the influenza more than 
a few days. 

This is an instructive example of an insidious combination of circum- 
stances very likely to mislead a practitioner ; for as the vomiting was for 
a day or two accompanied by a looseness of the bowels, the suspicion of 
hernia would not strike the attention. It is plain that in this case indi- 
gestion produced an increased and morbid activity in the motions of the 
alimentary canal, which led to the incarceration of the portion of gut. Up 
to a certain moment the symptoms depended merely on one cause; after 
that period, strangulation took place — an occurrence which could not be 
easily diagnosed, as vomiting, one of the most striking symptoms, had pre- 
viously existed. 

When diarrhoea occurs, it is generally at the commencement of the dis- 
ease ; and it is remarkable that this state is frequently exchanged, rather 
suddenly, for one of an opposite character. Thus, when you have suc- 
ceeded in checking the diarrhoea with chalk-mixture and opium, a state 
of costiveness will frequently ensue, requiring the daily use of purgatives 
and enemata. I have now witnessed several cases in which the moderate 
use of opiates and astringents brought on constipation, requiring the use 
of strong purgatives and enemata, thrown up with Read's syringe. 

In influenza, as in many other febrile affections, the lungs become con- 

of bleeding in mitigating the violent and painful cough which seems most expressly to require 
it; and the frequent success of remedies precisely the reverse of this ; all show a speciality in 
the disease, to which we must refer, more or less directly, in every question of practice. What- 
ever the cause or precise seat of irritation, it is certain that it has rarely the character of true 
membranous inflammation. In truth, the same reasons which prevent or limit bleeding in 
hooping-cough, apply no less to the peculiar cough and irritation of the influenza. We have 
rarely any authority for it in the state of the pulse, which neither in strength nor frequency 
bears relation to these inflammatory symptoms; while the difficult or painful respiration, which 
often suggests the remedy, furnishes evidence against its fitness by becoming frequently more 
laborious than before — the effect of larger accumulation in the bronchial cells, and of diminished 
power." — Op. cit., page 219. 



INFLUENZA. 471 

siderably engaged; the disease first attacks the nose and throat, then the 
larynx and trachea, and, finally, the ultimate ramifications of the bronchi. 
There are several other affections which commence in a similar way — as 
ordinary catarrh, bronchitis, and measles. In influenza, most persons have 
the nose and throat affected in the beginning ; the inflammation creeps 
gradually along the lining membrane of the air-passages, until it involves 
the greater part, or the whole, of the bronchial mucous membrane. The 
progress of the inflammation is extremely rapid, and in the course of twenty- 
four, or even twelve hours, the lungs become engaged. There is, how- 
ever, much difference as to the extent to which this inflammation proceeds. 
In many cases, it is limited to the nose and throat; the patients complain 
of coryza, hoarseness, and slight cough. In others, the trachea also is 
more or less affected, and the cough is more troublesome ; but, generally 
speaking, the latter as well as the former cases are unattended with fever. 
The patients eat and drink as usual, go about their ordinary business, and 
sleep tolerably well at night. This appears to be the general course of 
the disease when the inflammation is limited to the nose, throat, and upper 
part of the air-passages; when it spreads farther, and attacks the first rami- 
fications of the bronchi, there is some dyspncea and tightness of chest, the 
cough is much more troublesome, and the appetite and digestion are some- 
what impaired ; but persons in this state, although resting badly and eat- 
ing but little, will continue to go about — constantly, however, complain- 
ing that they are very ill. When the smaller divisions and ultimate rami- 
fications of the bronchi are engaged, there is soreness of chest, remarkable 
dyspnoea, and constant harassing cough; the headache is also aggravated, 
the patient loses all inclination for food, sleeps badly at night, and is con- 
fined to the bed or house. First, then, you have the mucous membrane 
of the eyes, nose and throat affected; then the larynx and trachea; then 
the larger bronchi ; and, finally, the smaller and more minute ramifications. 
When the latter state has continued for some time, more or less serous en- 
gorgement of the lung takes place, and this adds to the dyspnoea and cough. 
On applying the stethoscope over various parts of the lung, you will hear 
at various parts a moist crepitus, indicating the existence of serous infiltra- 
tion. The smaller bronchial tubes and air-vesicles are congested and filled 
with mucus ; the blood cannot pass freely through the lung, and conse- 
quently must be imperfectly aerated ; the secreting and absorbing functions 
of the lung are deranged, and hence arises a state in which the pulmonary 
capillaries become congested, and permit the more fluid part of the blood 
to exude into the parenchyma of the lung, giving rise to what is termed 
serous infiltration. Something similar to this occurs also in general bron- 
chitis, particularly in fever, but we very seldom have hepatization result- 
ing from such causes. In hepatization, the capillaries pour out, not serum, 
but lymph, which glues together the cells of the pulmonary tissue, and 
forms a dense solid mass. Hence, in influenza or bronchitis, you seldom 
have true pneumonic inflammation. You will have extensive and danger- 
ous engorgement, but when you examine the lung after death you do not 
find any real solidification, and you can restore the lung almost to its 
original permeability and buoyancy by squeezing out the infiltrated fluid. 
Yet 1 must admit that this is not always the case, and that in influenza, as 
well as in bronchitis, you may have true pneumonia superadded to the 
original affection of the lining membrane. This occurred in the case of a 
lady whom I attended in Capel-street, and who was attacked with influ- 



472 CLINICAL MEDICINE. 

enza shortly before delivery. On the day of her accouchement, pneumo- 
nia was superadded to the bronchial inflammation, and she died with ex- 
tensive hepatization of the right lung. This also occurred in the case of 
a man of middle age, residing in Suffolk-street, who had been labouring 
for some days under excessive engorgement of the lung. I have also ob- 
served the same occurrence in a gentleman whom I attended with Mr. 
Colles, in Exchequer-street ; and in another case which I saw in White- 
friar-street. 

One of the most singular features in the history of the present influenza, 
is the extraordinary degree of dyspnoea witnessed in most cases where the 
lung is extensively engaged, but particularly where the patients had been 
previously subject to pulmonary affections ; and even in many cases 
where the bronchial mucous membrane is but slightly engaged, the 
amount of dyspnoea is remarkably great. Indeed, it might be said with 
much truth, that the dyspnoea was by no means proportioned to the extent 
of pulmonary inflammation. There is at present in the hospital a woman 
labouring under influenza, whose chest sounds clear on percussion, and in 
whom every part of the lung is permeable, who presents nothing more than 
a few sonorous rales in the course of the larger bronchial tubes, and yet she 
is suffering from considerable dyspnoea, and the respirations amount to 
forty-six in a minute. We cannot, therefore, attribute the difficulty of 
breathing to mere bronchitic lesion, for it is not in proportion to this 
lesion. Another patient admitted into Sir P. Dun's Hospital exhibited a 
similar train of symptoms. He w 7 as a negro sailor, a native of New 
Brunswick, and was seized with the epidemic a few days after his ship 
arrived in Dublin ; he was a man of Herculean form and finely developed 
chest, and in the prime of life. His suffering from dyspnoea was intense ; 
his chest heaved, he tossed about in bed in a constant state of agitation 
and restlessness, and yet the respiratory murmur was everywhere dis- 
tinctly audible through the lung, and no rale could be heard, except 
here and there a few bronchitic wheezings. He also laboured under 
insomnia, and, though he had but little fever, his debility was extreme. 
Indeed, his pulse was so weak from the commencement, that I could not 
venture to treat him antiphlogistically ; and I accordingly ordered exten- 
sive vesication over the chest, with the use of wine, stimulants, and 
narcotics. This man subsequently recovered — an event which could 
scarcely have occurred under the plan of treatment adopted, had his 
dyspnoea depended on mere bronchitis. It should be also borne in mind, 
that in many bad cases of influenza the dyspnoea is intermittent, or at 
least undergoes remarkable exacerbations and remissions at certain hours 
of the day and night. It would appear that the respiratory derangement 
depends on the same general cause which produces the whole train of symp- 
toms, and that it might exist even where there was no bronchial inflam- 
mation at all. It is true, that where the bronchitis is present, it adds to 
the distress of respiration, but the dyspnoea appears to be chiefly attribu- 
table to some impression made on the vital activity of the lung. That 
the lungs are endowed with an inherent vitality necessary to the aeration 
of the blood, has been long acknowledged by the Germans, who have 
described a dyspnoea from paralysis of the lungs ; and this opinion is now 
generally adopted in Great Britain, since the results of the experiments on 
the eighth pair of nerves have been duly appreciated. We have abundant 
illustrations of this truth in asthma, in w T hich the greatest dyspnoea is 



INFLUENZA. 473 

often present, without any appreciable lesion of the lung. And it would 
be a fortunate circumstance for the patients in influenza, if this were not 
the case ; for we could then treat the affection of the lung as ordinary 
bronchitis, and should expect to find it amenable to the ordinary reme- 
dies. You are aware that the mortality in cases of ordinary bronchitis 
is extremely small, if we except very young children and persons 
advanced in life. In adults, when met by prompt and appropriate treat- 
ment, it is generally a very manageable disease, and seldom proves fatal, 
unless combined with other unfavourable conditions. This, however, is 
not the case in influenza, nor is the pulmonary affection so easily treated, 
or the dyspnoea so readily controlled. T saw, some time ago, a fine young 
woman, servant to a gentleman in Fitz w i 11 iana -street, for whom every 
thing had been done which the best and most skilful practice could 
devise ; but her condition, when I saw her, was desperate, and she died 
the following day : yet her chest sounded well on percussion, and we 
could hear nothing over the whole lung, except a few sonorous and 
sibilous rales, and the respiratory murmur seemed everywhere nearly as 
loud as natural. Of course, such a lesion of the nervous influence could 
not last long, without necessarily inducing pulmonary congestion — an 
inevitable consequence of imperfect aeration of blood. When the eighth 
pair of nerves is divided, the animal is slowly suffocated ; and, on dis- 
section, the lungs are found engorged, and the bronchial mucous mem- 
brane congested and inflamed. May not the affection of these parts in 
influenza be sometimes induced by lesions of nervous power in the lungs? 
I am indebted to my friend, Dr. George Green, Professor of the Practice 
of Physic to the College of Physicians, for the following results of his 
very numerous post-mortem examinations in this disease, and I feel great 
pleasure in being able to give them — as such examinations, at least in 
this country, are very rare. Dr. Green observes: — 

" The cases which proved fatal at the House of Industry, during the 
late epidemic influenza, occurred principally among the aged inmates of 
both sexes. I had an opportunity of examining several of these cases, 
and the following were the principal post-mortem appearances observed. 

" The bronchial mucous membrane was found, in every case, more or 
less congested and inflamed. The colour varied considerably — being in 
some of a dull red, and in others of a much darker hue. The inflamma- 
tion, in most cases, was found to occupy both the trachea and the bron- 
chial tubes of both lungs ; in other instances, it was confined to one lung 
alone. A sanguinolent frothy mucus occupied the area of the tubes, and 
increased in quantity as they were traced to their minuter divisions. The 
parenchymatous tissue of the lung was invariably discoloured, being gene- 
rally of a dark or violet colour ; its specific gravity was increased, and it 
did not crepitate, or at least very feebly, when pressed between the 
fingers. The surface of its section was not rough to the touch, and when 
pressed in the hand, a quantity of the mucus described above was driven 
out. In some cases, the postero-inferior portions of one or both lungs 
were very dark coloured, and the finger could be passed easily through 
its substance. When the surface thus torn was examined, it did not 
appear to be granular ; it resembled more a portion of gangrenous lung, 
except that there was an absence of fetor. This last appearance was 
found principally in very aged persons. It was rare to find any traces of 
the second and third stages of ordinary pneumonia in these patients ; but 



474 CLINICAL MEDICINE. 

in the young and robust, who were received into the Hard wick Fever 
Hospital from the neighbouring streets, these degenerations of the structure 
of the lung were observed, together with the same inflammation of the 
bronchial mucous membrane. 

" In most of the aged patients, the blood was found dark coloured and 
fluid in both cavities of the heart, and in every vessel where it was exa- 
mined. The cases in which fibrinous concretions in the cavities of the 
heart were found, were very few, and these invariably in the young or 
middle-aged. In the former class of patients, also, the lung occasionally 
appeared to be edematous ; and, in one or two cases, a considerable 
effusion of serum had taken place into the pleural cavities. The signs of 
recent pleuritis were very rare, but old adhesions, as might be expected 
in such subjects, were very commonly found between the pulmonary and 
costal pleurae. In one case of a lunatic, who survived the immediate 
attack of influenza, tubercles appeared to have been rapidly developed in 
both lungs. In another lunatic, two tubercular cavities were found in 
addition to the state of the lung and air-tubes already adverted to. 

" With respect to the nature and duration of the symptoms of those 
cases which came under my own management, I have little to say in 
addition to what is already so familiarly known. The physical signs 
afforded by percussion and auscultation were almost universally as fol- 
lows : — Dulness, more or less decidedly marked, in the postero-inferior 
portions of the lungs ; sonorous or some form of the bronchial rales through- 
out the chest, or, what was more common, a mixed sonorous and crepi- 
tating rale, or, in the latter stages, a muco-crepitating rale. The sputa 
were seldom rusty-coloured or tenacious, but rather resembled those of 
bronchitis. In many cases, the want of power to excrete them appeared 
to be the immediate cause of death ; but in others, the morbid cause, 
whatever it might be, appeared to have affected the entire respiratory and 
circulating systems, producing great congestion of the venous system, and 
a state not unlike asphyxia. The latter cases were almost all among the 
aged inmates of the House of Industry. 

" The appearances of the other viscera were not such as could in any 
way account for the result, so often speedily fatal ; so that, so far as one 
could hazard a conjecture, the morbid cause appeared to have made its 
primary impression on the respiratory mucous surface, thereby interfering 
with the proper aeration of the blood, and inducing the changes in that 
fluid and in the structure of the lungs above detailed." 

Such are the appearances observed by Dr. Green in his numerous dis- 
sections of persons who died of influenza. They may be relied on as 
perfectly accurate, for no one is better acquainted with pathological phe- 
nomena than Dr. Green, and consequently no one better able to furnish 
valuable evidence with respect to the appreciable changes produced by 
influenza in the pulmonary and other tissues. 

I have already advanced the opinion, that we should not hastily assume 
that influenza consists essentially in the morbid changes which dissection 
reveals ; we should examine every side of the question, and consider 
whether it is not possible that the alterations in the pulmonary tissue may 
not be, to some extent at least, the consequences of the disease. Let us 
consider for a moment the method we pursue in reasoning about the pro- 
gress and causes of the symptoms in ordinary bronchitis. Here a patient 
is seized with a pectoral affection, attended by cough, dyspnoea, and more 



INFLUENZA. 475 

or less fever. We find certain rales, and the expectoration is altered in 
quality and quantity. Further, observing a number of such cases, we 
remark that the danger is proportioned to the degree of dyspnoea, and the 
dyspnoea to the extent and nature of the rales, together with the quantity 
and quality of the expectoration. To these the general constitutional 
affection, and the probable results of the disease, have certain definite 
relations, a knowledge of which is soon obtained by experience. But 
these rales, and this state of the respiration and expectoration, we have 
reason to believe, arise from the presence of bronchial inflammation ; and 
to this we refer all the symptoms observed. On this supposition, too, we 
proceed in our treatment, and the result most commonly justifies its cor- 
rectness; and we have additional evidence of its truth furnished by post- 
mortem examinations. Now, in such instances, the chain of inductive 
evidence is complete, and we feel a conviction that our practice is founded 
on correct notions of the nature of the disease. But how different is the 
case when we assume that influenza is caused by bronchial inflammation ! 
In influenza, the dyspnoea is not always proportioned to the bronchitic 
affection — nay, in some cases we have seen that difficulty of breathing 
was most urgent in cases where the air entered into all parts of the lung 
with facility, and where few and unimportant rales existed. Again, 
although the presence of a copious viscid secretion in the bronchial tubes 
was sure to aggravate dyspnoea, yet it often occurred in patients whose 
air-passages were very little, or not at all, obstructed in this way. The 
effects, too, of remedies, antiphlogistic, expectorant, and derivative, were 
very different from What they would have been had the disease depended 
on a mere bronchitis. T have already stated my conviction, that the poi- 
son which produced influenza acted on the nervous system in general, 
and on the pulmonary nerves in particular, in such a way as to produce 
symptoms of bronchial irritation and dyspnoea, to which bronchial conges- 
tion and inflammation were often superadded. 

In this view of the subject I am not singular, for I find that it has been 
advocated by Dr. Peyton Blakiston, in a short treatise on influenza, as it 
occurred at Birmingham. He states that his researches have led him to 
the conclusion, u that influenza is an affection of the nervous system, with 
its concomitant derangements in the organs of digestion, circulation, &c, 
commonly known under the name of nervous fever, accompanied through- 
out its whole course by irritation of the pulmonary mucous membrane, 
which not unfrequently amounts to congestion, and even to inflamma- 
tion." 

This distinction between influenza and feverish cold with bronchitis, 
is, in a practical point of view, of great importance, and should never be 
lost sight of in the treatment of influenza — for it prevents us from placing 
our sole confidence in remedies adapted to mere bronchitic inflammation. 
Thus, Dr. Blakiston asserts, and most physicians will agree with him in 
this point at least, that it was often necessary to have recourse to diffusible 
stimulants at the commencement, and to administer tonic medicines in an 
early stage of the disease. 

In some cases, even where great dyspnoea exists, the cough is hard and 
dry, and the expectoration scanty ; in others, the expectoration is copious, 
so as to cause constant efforts to cough it up ; and, indeed, it is melan- 
choly to look at the distress which patients suffer in this respect. You 
will hear the wheezing of the phlegm in the throat and air-passages be- 



476 CLINICAL MEDICINE. 

fore you enter the room, and you will see the patient exhausted by suc- 
cessive paroxysms of cough, and ineffectual attempts to expectorate. In 
other cases, where the vitality of the lung is less injured and the general 
tone of the system less deranged, the sputa, although copious, are expec- 
torated with considerable facility. The sputa bear considerable analogy 
to those observed in ordinary bronchitis ; they consist at first of a greyish 
mucus, which, as the disease proceeds, exhibits a globular appearance, or 
assumes a puriform character, and does not coalesce ; in other cases they 
are extremely viscid and ropy, like solutions of gum or isinglass. A re- 
markable fact with respect to the sputa in influenza is, that they are very 
seldom mixed with air-bubbles. On mentioning this to-day to some per- 
sons attending my class, I was shown some sputa discharged by a patient 
labouring under influenza, in which there were some air-bubbles ; this, 
however, is extremely rare. In a lecture which was delivered here some 
time ago, I took occasion to allude to the secretions of the bronchial 
mucous membrane, and stated my conviction that this subject had not re- 
ceived as yet the attention which its acknowledged importance demands. 
There is one point, in particular, of which no adequate explanation has 
been as yet given — namely, why it is that in some cases ,of pulmonary- 
inflammation the sputa are filled with air-bubbles, while in other in- 
stances, there is no appearance of air-bubbles from the beginning to 
the end of the disease. The presence of air-bubbles in the sputa has been 
explained, by supposing that air becomes incorporated with the mucus 
while it is driven up and down in the bronchial tubes during the acts of 
respiration and coughing; just as if you shake a solution of soap or any 
other viscid fluid in a half-empty bottle, it becomes impregnated with air- 
bubbles. There may be some truth in this, but I think it does not suffi- 
ciently explain the presence and intimate incorporation of air with the 
sputa in certain affections of the lung ; and it appears to me that we can 
scarcely understand this, unless we suppose that the air and mucus are 
secreted together. You are aware that air is secreted by the bronchial 
mucous membrane, and that in some cases this secretion is morbidly in- 
creased, in others morbidly diminished. Now, it is not very unreason- 
able to suppose that the mucous membrane may secrete air and mucus 
together in abnormal quantity ; and that this, rather than any mechanical 
agitation, may be the cause of the intimate combination of air with the 
expectorated fluids. 

I need scarcely make any observation on the cough in influenza. It is 
in general very troublesome, particularly at night. Many persons are not 
much annoyed by it during the day, but at night it becomes very harass- 
ing, and prevents them from sleeping. When severe, it continues both 
night and day; and even when persons have recovered from the fever and 
dyspnoea, and are able to go about, the cough will continue extremely trouble- 
some: this I have observed in the majority of cases. In this state medi- 
cines prove of very little service, and one of the best remedies is to change 
to a mild country air. Cases of cough, in w T hich I had tried every 
remedy without success, and which had resisted every form of treatment in 
the city, yielded in a few days to the salubrious influence of change of air. 

In influenza, the urine is generally much loaded with lithates and super- 
lithates, and contains a large quantity of erythric or purpuric acid. It is 
red when voided, deposits a good deal of sediment, and tinges the vessel 
in which it lies with a pink film. It bears some resemblance to the urine 



INFLUENZA. 477 

which accompanies arthritic and gouty affections. In very bad cases, this 
state of the urine continues up to the period of death. You recollect what 
I stated with regard to the condition of the blood ; it is generally buffed, 
even where there is scarcely any febrile excitement in the system, and 
thus affords a very fallacious indication. The same observation holds 
good with respect to the state of the urine and the temperature of the skin. 
I may observe here that the heat of skin is very variable ; it is sometimes 
very high, sometimes natural ; in fact, like the pulse, it falls and rises in 
a very remarkable manner, at certain times in the day. 

I have already spoken of the affection of the mucous membrane of the 
bowels. I may observe, that in some cases of influenza the morbid influ- 
ence is translated to the brain, and symptoms of delirium or coma super- 
vene. Thus, in two instances that have been communicated to me, the 
patients fell into a state resembling coma, during the course of the disease. 
In three cases witnessed by the late Mr. Swift, the attack of influenza ter- 
minated in a train of symptoms bearing a close analogy to delirium tre- 
mens, and requiring the use of blisters to the head and nucha, full doses 
of opium, purgative enemata, wine, and the occasional use of mercurials. 
The patients complained of great headache, noise in the ears, some intoler- 
ance of light, and more or less sleeplessness from the commencement, along 
with the usual pulmonary symptoms. After five or six days, they became 
excessively nervous, lost all sleep, had continued subsultus and tremours, 
and talked very incoherently, particularly at night. During the preva- 
lence of the cerebral symptoms, the pulmonary affection partially or wholly 
disappeared, but returned again in some degree after the subsidence of the 
delirium. All these cases terminated favourably. 

I believe I have already remarked, that many persons who have laboured 
under very severe pulmonary symptoms will struggle through the disease ; 
and I may mention here that I have seen persons recover, who have suf- 
fered from continued orthopnoea for three weeks. Still the mortality, par- 
ticularly among the aged, is very great ; and I fear that we shall shortly 
have but a few octogenarians to tell the occurrences of the last century. 
Indeed, the mortality has not been confined exclusively to the aged, for 
many persons in the vigour of life have sunk under the attack. There 
have been several deaths among the soldiers in our garrisons, notwithstand- 
ing the excellent state of health which our troops generally enjoy, and the 
skilful and judicious treatment of our present army surgeons. The results 
of the medical treatment and necroscopic observations in the different regi- 
ments in London, Dublin, and Edinburgh, will form a most valuable docu- 
ment, and I hope it will be made public for the benefit of the whole pro- 
fession. 

It now remains for me to say a few words concerning treatment. First, 
as to bleeding. A great deal was expected from general bleeding, because 
the disease was sudden and violent in its onset, and accompanied by symp- 
toms which seemed to require active measures — such as an inflammatory 
state of the bronchial mucous membrane, accompanied by quick pulse, hot 
skin, and high-coloured urine. This led persons to expect much benefit 
from venesection. The results, however, of its employment are, gene- 
rally speaking, unsatisfactory. Where venesection was employed promptly 
and in the beginning of the disease, and where it seemed to be strongly 
indicated by the buffed and cupped state of the blood, even in such cases 
it has failed to afford any thing like material or permanent benefit, or to 



478 CLINICAL MEDICINE. 

produce a decided amelioration of the existing symptoms. The general 
impression among practitioners in Dublin at present seems to be, that 
bleeding is doubtful in its effects, if not altogether improper. I am much 
inclined to think that bleeding, unless employed within the first twelve or 
twenty-four hours, will be likely to do as much or more harm than good. 
Bleeding on the second or third day, except to relieve congestion of the 
lungs, seems inadmissible. The same observation holds good with refer- 
ence to other diseases. Thus, in scarlatina, if you happen to be called in 
when the rigor commences, and while the disease is beginning to form, 
you will sometimes accomplish much good by bleeding your patient; but 
after eighteen or twenty-four hours, when the disease is fully formed, vene- 
section will not do. On this point I can speak from experience. In scar- 
latina, the difference of a few hours renders venesection inapplicable, and 
even injurious. It is the same thing with respect to influenza; general 
bleeding is useful only in the commencement, and, where the symptoms 
seem to demand it, it should be employed at least within the first twenty- 
four hours. Where I have been fortunate enough to find the disease just 
commencing, I bleed to the amount of twelve or fourteen ounces, order 
the patient to remain in bed and take some aperient, followed by the use 
of nitre. In this way, by timely bleeding, aperients, sudorifics, and con- 
finement to bed, the attack generally passes over in two or three days. 
I could mention many instances of the success of this plan of treatment. 
In one family I treated all the individuals attacked in this way, and I have 
done the same thing in many cases of persons somewhat advanced in life. 
In the case of an old gentleman, who was very severely attacked, I suc- 
ceeded by these means in checking the disease at once. My experience, 
therefore, is, that bleeding is of service in the very commencement of the 
disease; but as it seldom happens that a physician is called in at this pe- 
riod, I would qualify my statement by saying, that, as a general measure, 
bleeding in influenza is seldom admissible. When you are called on to 
attend cases, you will most generally find that the patients have been ill 
for two or three days or more ; and then the only mode of abstracting 
blood, which you can have recourse to with safety, is by leeching. About 
eight or ten leeches applied over the hollow of the neck, just above the 
sternum, and allowed to bleed pretty freely, will prove very serviceable; 
and if you apply them in the evening, you will often secure to your pa- 
tient a good night's rest. This plan of leeching the hollow of the neck, 
in cases of tracheo-bronchial inflammation, is an excellent one: the leeches 
are applied at a spot which lies close to the trachea, and particularly to 
that point to which the irritation accompanying bronchitic affections is 
chiefly referred. 

By the aid of leeching, the use of aperients, if necessary, and confine- 
ment to bed, with sudorifics, you will frequently succeed in removing the 
fever and bronchial inflammation. You will derive much benefit, parti- 
cularly in the early stage of influenza, from tartar emetic and nitre ; but 
I must say, that neither leeching nor tartar emetic and nitre prove as 
valuable and as efficacious, in influenza, as they do in ordinary bronchitis. 
Some of my friends, who used tartar emetic as a nauseant in the com- 
mencement of the disease, inform me that they have derived benefit from 
its use ; and others have told me that they have used tartar emetic and 
opium in the commencement and during the course of the disease, with 
advantage. I have not employed the first of these, but I have the latter, 



INFLUENZA. 479 

and with favourable results. You may, therefore, after using antiphlo- 
gistics for a day or two, proceed to the use of opiates, in combination 
with tartar emetic or nitre. In some cases, the camphorated tincture of 
opium will answer very well ; in others, you will find the acetate or mu- 
riate of morphia better. A mixture, composed of six ounces of almond 
emulsion, a drachm of nitre, and half a drachm or more of the liquor 
muriatis morphise, will be found very useful. The muriate of morphia, 
which possesses many of the valuable properties of opium without its de- 
fects, will serve to tranquilize the system and produce sleep — two most 
important points in a disease like influenza connected with increased ner- 
vous irritability.* A gentleman, on whom I place much reliance, tells 
me that he has treated many bad cases successfully with camphor-mixture, 
tincture of opium, and tartar emetic. I need not mention the various 
remedies which have been recommended in this disease — as Mindererus's 
spirit, Hoffman's anodyne, ipecacuanha, alone or combined with extract 
of conium and blue pill, and many other remedies belonging to the class 
of diaphoretics or expectorants. They are all more or less serviceable, 
but they have all the common defect of producing less relief than they 
usually do in cases where the pulmonary affection is simple and idiopathic. 
Towards the end of the disease, you find it necessary to give stimulating 
expectorants and light tonics — as decoction of polygala senega, infusion 
of columba, &c, &c.f 

One word about blisters, before I conclude. They are useful in some 
cases, but in many of the severe ones they do little or no good, and only 
add to the patient's sufferings. They do not relieve the pulmonary symp- 
toms, and particularly the dyspnoea, in the manner you would be prepared 
to expect. I do not know a more remarkable circumstance, in the pre- 
sent disease, than the failure of blisters : and in many cases I do not era- 
ploy them at all. Fomenting the trachea and chest with very hot water 
appearstobe much more serviceable. This has proved extremely valuable in 
many cases of this as well as other affections of the air-passages : and on 
referring to the late American journals, I find that the plan of treating 
croup in its onset, by means of very hot water applied with a sponge to 
the throat — a plan which I recommended some time ago in the Dublin 
Medical Journal — has been extensively employed in America, and with 
the most happy results. Sponging the throat and chest with water, as 
hot as it can be borne, has been found, in many instances, capable of 
arresting all the threatening symptoms of croup at once. Several cases 
are mentioned in the American journals, in which the lives of the little 
patients were evidently saved by this application. I may state, also, that 
not long since a child was saved in Dublin by the same means. By the 
advice of Mr. Smyly, who suspected the threatened attack, the child's 

* I cannot agree with Dr. Holland in the following opinion concerning opium : " It seems 
necessary to add opium to the list of medicines, from which little certain benefit is to be had 
in this disorder. The restlessness at night, which is so general a symptom, would seem to 
require its use; but from some cause or other, it is rarely effectual in giving much relief: and, 
though the cough may for a while be mitigated or suppressed by this remedy, it is doubtful 
whether the good so obtained is an equivalent to the disadvantages in various ways incurred." 
— Op. cit., p. 219. 

■J- Dr. Blakiston strongly recommends the etherial tincture of lobelia, in large doses, repeated 
at short intervals, in influenza where bronchitis was present. As I had not the advantage of 
perusing his book during the prevalence of the epidemic (it was not published till May), I had 
no opportunity of trying this medicine in the way he suggests. 



480 CLINICAL MEDICINE. 

mother had every thing prepared, and by her promptitude and care arrested 
the disease before it had sufficient time to form. 

I have nothing more at present to add to the subject of influenza ; we 
are still much in the dark as to the best mode of giving relief — and this 
is the more singular, as in general the disease allows full time for the trial 
and operation of medical agents. 



LECTURE XXXVIII. 

Connection between diseases of different organs ; between arthritis, jaundice, and urticaria;. 
between periostitis produced by abuse of mercury, and hypertrophy of the liver — Details of 
cases illustrating this connection — Its explanation — Hypertrophy of the liver produced by 
scrofula — Enlargement and inflammation of the liver after scarlatina — Importance of recog- 
nising this disease — Connection between disease of the liver and disease of the he;irt — 
Chronic hepatitis from this source, curable in young persons — Enlargement of the spleen 
connected with superficial ulceration of the legs — Erysipelas and gangrene, sometimes of a 
pseudo-inflammatory character — Treatment of this form of the disease. 

In order to acquire a correct and available knowledge' of human pathology, 
and to extend the range and confirm the accuracy of diagnosis, it is of 
the utmost importance to observe attentively the connection between 
the diseases of certain organs or systems of the body. You are aware that 
some organs, when labouring under disease, are apt, after the disease has 
continued some time, to implicate other organs, giving rise to various 
deranged conditions,, which are developed, sometimes simultaneously, but 
in general consecutively, and in sequence. I have already pointed out 
several diseased actions thus associated together, each forming a link in the 
morbid chain. Now it is of the greatest importance to study each link, and 
ascertain the nature of its connection, so as to have a distinct conception of 
the whole. Last session I directed the attention of my class to a train of mor- 
bid phenomena sometimes observed coexisting with arthritic inflammation. 
A person labouring under inflammation of the joints gets an attack of hepa- 
titis, accompanied by jaundice, and this is followed by urticaria. I have ob- 
served thissequence of disease in eight or nine cases. The first was in a gen- 
tleman residing in Lower Mount Street, whom I attended with Dr. Cheyne. 
This gentleman, in consequence of exposure to cold, was attacked with 
arthritic inflammation and fever. After he had been about ten days ill, 
he became suddenly jaundiced, and in a day or two afterwards a copious 
eruption of urticaria appeared over his body and limbs. Exactly the 
same train of phenomena, and in a similar order of succession, were 
observed in a man treated in the Meath Hospital in 1832. A short time 
before this, I had been attending a medical friend in Baggot Street, who 
had been affected in the same way ; and I mentioned to the class, as soon 
as I perceived the man was jaundiced, that he would most probably get 
urticaria. I made a similar prediction in a case which occurred recently 
in our wards, and it was verified by the event. Now this is not a mere 
fortuitous occurrence ; the various symptoms must be connected in the 
relation of cause and effect. It is interesting to bear this in mind, and it 
is besides of considerable importance to the practising physician ; it enables 
him to predict the appearance and form of disease, and inspires his patient 
with confidence in his opinions and judgment. 



PERIOSTITIS WITH HYPERTROPHY OF THE LIVER. 481 

There is another sequence of disease, not unfrequently observed, but of 
which the connection has not been hitherto noticed h^ any writer, as far 
as I can ascertain. About two years since, I was consulted by an English 
gentleman, who had been ill for a considerable time. The history of his 
case from the commencement was this: — Three years previously he had 
venereal, — used and abused mercury, — was exposed to cold, and got 
periostitis. He now got into a bad state of health, used mercury a 
M'cori'l time, obtained some relief, and then relapsed again ; finally, after 
having used mercury three or four times, he was attacked with mercurial 
cachexy, became weak and emaciated ; the periostitis degenerated into 
ostitis, producing superficial caries and nodes of a bad character ; he had 
exfoliation of the bones of the cranium, and rupia, and was reduced to a 
most miserable state. Under our care the symptoms gradually disap- 
peared ; he recovered to all appearance, and even got fat. He then 
caught cold and relapsed again. At last his liver became engaged ; he 
was attacked with hypertrophy of the liver, ascites, and jaundice, and 
died soon afterwards. Here, then, we have venereal, abuse of mercury, 
periostitic inflammation, abuse of mercury followed by exacerbation of the 
periostitis, and the establishment of mercurial cachexy, and the history of 
the case is wound up with hypertrophy of the liver. This was the first 
case in which I had observed this concatenation of diseases; since that 
period I have seen a similar train of morbid phenomena, twice in private 
practice and once in hospital. First we have abuse of mercury, then 
periostitic inflammation and mercurial cachexy, and the scene is closed 
by morbid enlargement of the liver. Now I do not look upon this 
sequence as merely fortuitous. The diseased actions are, I ttynk, related 
as cause and effect, and each successive condition is consequent on the 
previous one. It may not be amiss to mention here some curious circum- 
stances observed in the case to which I have just alluded. While this 
gentleman's liver was enlarging, there was no tenderness of the right 
hypochondrium on pressure. I have observed the same absence of ten- 
derness in all the cases of this description which I have witnessed. The 
gentleman could bear pressure over the hepatic region without any incon- 
venience, and yet the liver was so enormously increased in size, that its 
inferior margin extended almost down to the pelvis. What is equally 
remarkable, he had no fever, and the tongue was perfectly clean and moist 
during the whole course of the hepatic affection. In ray observations on 
a case in the fever ward, 1 remarked a few days since that some persons 
were too hasty in drawing inferences from the state of the tongue as to the 
existence of affections of the digestive organs. I shall not touch on this 
point, however, at present, and shall merely observe that this gentleman's 
tongue was perfectly clean and moist, notwithstanding the morbid con- 
dition and rapid growth of the liver. Another curious circumstance was, 
that during the hepatic affection, digestion appeared to go on very well, at 
least so far as the formation and due expulsion of feces are concerned. 
The alvine evacuations were regular, and the matter discharged presented 
the form and consistence of that which is passed by a person in good 
health. But there was a peculiarity in it to which my attention was first 
directed by the patient, who was an intelligent and observant person. 
The cylinder of fecal matter was composed of parts differing in colour 
and appearance : two or three inches consisted of pale clay-coloured sub- 
stance ; and immediately after this another portion, of about the same 
32 



482 CLINICAL MEDICINE. 

length, was observed, presenting the ordinary bilious or brown colour of 
natural excrement ; and then again another mass of clay-coloured matter, 
without any obvious trace of bile. This appearance I have now fre- 
quently witnessed ; and the inference to be drawn from it is this, — that 
in such forms of hepatic disease the functions of the liver are performed, 
as it were, intermittently ; it secretes bile during a certain period of the 
digestive process, then stops, then secretes again. 

This peculiarity is noticed in many diseases of the liver; and it is im- 
portant to remark, in attempting to explain the rationale of these hepatic 
affections, that in no disease of the liver is this symptom more frequently 
observed than in the scrofulous. Scrofulous disease of the liver is that 
state in which there is an increase of size in the organ, with induration 
and imperfect secretion, but without any remarkable tenderness. This 
condition in children is accompanied with irritability of the digestive 
organs, fretfulness, emaciation, loss of sleep, and impaired nutrition. The 
little patient becomes what is termed " pot-bellied," and labours under 
thirst, debility, and febrile excitement. This has been frequently called 
remittent fever, and disease of the mesenteric glands, but in my opinion 
unjustly. It is only a form of general cachexy connected with the scro- 
fulous diathesis, affecting secretion and nutrition in general, and the 
digestive and biliary systems in particular. It would be quite wrong to 
imagine, that in this form of disease the liver is the cause of the whole 
train of morbid phenomena ; it is merely affected in common with other 
organs, and forms only an individual feature in the group of symptoms. 

Now, in this form of scrofulous cachexy, where you have diarrhoea, 
emaciation ^fever, thirst, and restlessness, the liver is frequently affected 
an the manner already described ; and in the loose stools of such a child, 
you will find one part bilious, another part clay-coloured ; they will be 
yellow to-day, and pale the next, accordingly as the liver secretes bile or 
vsuspends its functions. But in this instance, I repeat that the liver is 
only one of many organs affected by the same general cachexy. Could 
we ascertain the derangements of other secreting organs with the same 
facility, it is very probable we should find similar evidences of the morbid 
influence which pervades the whole system. 

This view of the question shows, that you are not to expect to succeed 
in removing the disease by the use of calomel or any other mercurial pre- 
paration. Many of those persons whose practice is little better than rou- 
tine, w<he.n called to treat a case of this description, first examine or in- 
quire as to the nature of the alvine evacuations, and fixing on the single 
symptom of deficiency of bile, immediately prescribe calomel, to be re- 
peated or continued until the secretion of the liver is established ; but 
they forget that this state of the biliary system depends on the general 
state of health, and that the absence of bile is the consequence, and not 
the cause of the disease. Almost all the organs of the body are affected ; 
and though calomel may restore the secretion of the liver for a time, it 
cannot bring back the organ to its natural state, or cure the disease. The 
malady is to be remedied in a different way : the secretions (and that of 
the liver among the rest) are to be improved by change of air, by an ap- 
propriate diet, by exercise, tepid or cold bathing, and the use of those 
remedies which are adapted to modify or correct that state of the system 
on which the general derangement depends. 

An observation of such cases has led me to a train of reflection respect- 



HYPERTROPHY OF LIVER FROM ABUSE OF MERCURY. 483 

ing the occurrence of the same order of symptoms in persons who have 
been injured by the abuse of mercury. Many persons who get venereal 
employ mercury injudiciously, and fall into what has been termed the mer- 
curial cachexy, in which there is a general unhealthy state of the organs. 
A patient who has fallen into this state very closely resembles a scrofulous 
person, and is apt to labour under the same emaciation, impaired nutrition, 
irritability, feverishness, and the same sort of cutaneous, glandular, and 
periostitic affections. The chronic mercurial cachexy is very like the 
scrofulous, and attacks very nearly the same organs and tissues. Hence 
the difficulty of curing affections of the liver, and other organs, when 
they are the result of this depraved habit. This is the key to the expla- 
nation of those horrible ravages which we frequently witness in cases of 
venereal disease complicated with mercurial cachexy — a state of consti- 
tution which is closely allied to the scrofulous. You will frequently meet 
with this consecutive affection of the liver in cases of morbus coxae, where 
the patient has been labouring for years under ulceration of the joint. 
The growth of the rest of the body appears checked, the patient is stunted 
and emaciated, while the liver increases rapidly in size. It was from 
observing the occurrence of liver disease in persons labouring under the 
scrofulous cachexy, that my attention was first turned to its occurrence in 
persons broken down by long or injudicious courses of mercury. 

One word, gentlemen, as to the curability of hepatic affections of this 
kind. I believe that it is always an unpromising form of disease ; but 
persons of originally good constitution, and under the age of thirty, will 
generally escape, if treated judiciously, and with proper care and atten- 
tion. Some months ago I attended, with Sir Henry Marsh, a young gen- 
tleman labouring under this affection, as a consequence of the abuse of 
mercury. We found him greatly emaciated, and labouring under consi- 
derable enlargement of the liver, with commencing ascites. He had also 
great determination of blood to the abdomen, diarrhcea, and hemorrhoids. 
By strict attention to his bowels a well-regulated diet, change of air, and 
the use of taraxacum, conium, and hydriodate of potash, he was ultimately 
cured, after an illness of nearly two years, during which the liver had 
grown to an enormous size. I may state, that he is at present in good 
health, and that the liver is nearly reduced to its natural dimensions ; this 
gentleman's age is about four-and-twenty. 

I observed one circumstance in the progress of this case which is worth 
noting. He was suddenly attacked with a papular form of purpura, ac- 
companied by much tingling and itchiness, and answering to the de- 
scription given of Purpura urticans. This peculiar eruption was very 
troublesome at night, and formed several successive crops, which alto- 
gether lasted a month. It occupied the extremities, upper and lower, 
and was very abundant on the latter. The gentleman wore a bandage 
to relieve a varicose state of the veins of the left leg. Now the eruption 
never appeared in the parts subjected to the pressure of the bandage, 
although it was very thick immediately below and above those parts. 

In persons below thirty the liver may become enlarged to a very con- 
siderable extent, and yet return again to its natural size under proper 
treatment. I could point out several persons in Dublin, in whom the 
liver had been so much enlarged, that I thought their case hopeless, and 
yet they have recovered, and are at present in the enjoyment of good 
health. The process by which the organ returns to its natural state and 



484 CLINICAL MEDICINE. 

dimensions is generally slow ; in two or three cases it occupied a space 
of time varying from one to two years. I attended a gentleman some 
time ago with Mr. Carmichael ; and from the history of the case, as well 
as the symptoms present, we were induced to look upon it as incurable ; 
and yet the patient has completely recovered. The late Mr. Macnamara 
and I attended a lady who had a very remarkable enlargement of the 
liver, but in the course of a year the viscus diminished so much in size, 
as to be very little above the normal dimensions. Within the last year 
(1842) Dr. Stokes and I have treated successfully an old gentleman be- 
tween seventy and eighty years of age, who had an enormously enlarged 
liver and ascites. We agreed to try a combination of blue pill and hy- 
driodate of potash. This he took for nearly six months, and its use was 
attended by a visible, almost daily, decrease in the size of the liver, and 
his general health gradually improved. He took the pills for a couple of 
months before his mouth got a little sore ; but full salivation was not pro- 
duced. He called on us a few weeks ago to thank us for our successful 
treatment, and took no small pleasure in directing attention to his altered 
appearance and renovated health. This is a matter of no common interest ; 
for cases of this description have been generally looked upon as beyond 
the reach of medical aid. You should, therefore, be very careful in your 
prognosis of such cases, and not give them up at once as incurable. 

I may observe in conclusion, that it is entirely as the result of the ca- 
chectic habit that this enlargement of the liver is observed. 1 have 
assumed this principle as the basis of my argument, and I think it is 
founded in fact and truth. It is also curious to observe, that the same 
cachectic state which gives rise to emaciation and decay of the body, 
generally occasions hypertrophy of some particular organs. What we 
most commonly observe in such conditions is, general wasting of the 
system, accompanied by increased morbid nutrition in certain organs. 
This appears to be the general law. You perceive that in the explanation 
I have given, I have supposed that enlarged liver is the result of a general 
cachectic state of the system, and it is of importance to recollect, that this 
state may be brought on by the injudicious exhibition of mercury, or by 
carrying mercurialization further than the constitution will bear. In this 
instance, we are compelled to allow, that our practice may furnish wea- 
pons to be turned against us by the disciples of homoeopathy. It cannot, 
however, be denied, that the immoderate use of mercury has been pro- 
ductive of liver disease. The late Mr. Hewson pointed out this to the 
attention of those who visited the Lock Hospital while under his care. 
At this period it was the custom to salivate every patient, and keep him 
under the full mercurial influence for a month or two ; and it frequently 
happened, that just as the mercurial course was finished, the patient got 
disease and enlargement of the liver. Were I inclined to theorise, I 
might, perhaps, offer some fanciful hypothesis in explanation of this oc- 
currence, and might trace some connection between the stimulant effects 
of mercury on the liver, and the subsequent hypertrophy. I shall, how- 
ever, content myself at present with noticing the fact, and leave the ex- 
planation to my juniors, who always explain matters, according to my 
observation, much more readily than their seniors. 

There are also other diseased states of the system, in which we have 
enlargement and morbid alteration of the liver. I can point out to you 
four different states of the system in which hypertrophy and disease of 



ENLARGEMENT OF THE LIVER FROM SCARLATINA. 485 

the liver forms one of the results of the general affection of the system. 
The next of those to which I shall direct your attention is scarlatina. 
Those who have attended the wards during the past month have seen ex- 
amples of this. We have observed during the same week two patients 
labouring under scarlatina, who got disease of the liver and jaundice. 
One of the patients, a little boy, was attacked with the disease in an ex- 
tremely violent form, accompanied with high fever, and a very remarkable 
eruption. In afew hours after the exanthema appeared, the entire cutaneous 
surface was dyed of a brilliant red ; in fact, the skin looked as if it had 
been painted over, and there was not a single spot free. In cases of this 
kind the violence of the cutaneous inflammation is sufficient to kill, with- 
out any other unfavourable complication ; and the patient seldom lives 
more than three or four days. You observed in this case, that the whole 
epidermis peeled off. But what I wish to direct your attention to is, that 
this boy after two days had evident symptoms of disease and enlargement 
of the liver. A young man, in the same ward, had also an attack of 
scarlatina, but in a milder form. On the third day he likewise got inflam- 
mation of the liver, but was cured by general and local antiphlogistic 
treatment. You are aware that scarlatina is one of those diseases in which 
a train of unfavourable sequelae are apt to remain after the removal of the 
original complaint. Persons, after recovering from the exanthematous 
fever, will sometimes get into a bad state of health, and instead of con- 
valescing, become restless and feverish towards evening, have an irritable 
jerking pulse, hot skin, derangement of the digestive organs, diminished 
urinary secretion, and finally become dropsical. Now, from observing 
the supervention of hepatic disease in such cases, both in hospital and 
private practice, my attention has been directed to the liver; and I never 
omit making an examination of that organ when called to treat those 
symptoms which are looked upon as the sequelae of scarlatina. In many 
of these patients I have found the liver in a state of inflammation of 
rather a chronic character, and without any of that remarkable pain or 
tenderness which characterizes acute hepatitis. But still it was inflamed, 
as proved by the benefit derived from local antiphlogistic means; and, 
moreover, its condition appeared to retard and prevent convalescence. 
Not long since, a friend of mine, a very intelligent practitioner, who was 
attending a case of this description, and had tried a variety of remedies 
without any benefit, was very much surprised when I drew down the 
bed-clothes and showed him that the liver was diseased. He had not 
thought of the existence of any thing like an hepatic affection, and was 
very much surprised that his treatment had proved so ineffectual. By 
the use of leeches to the right hypochondrium, the employment of mer- 
cury, and a proper regulation of diet, the patient was soon relieved, and 
the fever, thirst, and anasarca, quickly disappeared. In cases of this 
kind, the hepatic affection is the result of the general inflammatory diathe- 
sis, superinduced by scarlatina. You are all aware that nothing is more 
common after scarlatina, than inflammation of various organs. Thus some 
persons are attacked with pleuritis, some with pneumonia, others with in- 
flammation of the liver. Many persons continue in a valetudinary state 
after the eruption has declined ; they do not convalesce according to our 
expectations ; the pulse remains rather quicker than natural ; the bowels 
are deranged ; the appetite bad ; thirst urgent ; and urine scanty. In 
many of these cases you will find that there is a species of chronic hepa- 



486 CLINICAL MEDICINE. 

titis going on, which keeps up the feverishness, and retards convalescence. 
This is a point of great importance, to which I am the more anxious to 
draw your attention, because even the latest writers on scarlatina have 
either entirely omitted or very insufficiently noticed it. 

There is another organ whose morbid affections frequently implicate the 
liver; I allude here to the heart. I have already spoken of certain ca- 
chectic states, in w 7 hich the liver becomes enlarged and hypertrophied as 
the result of the general derangement of the system. In the present case 
the hypertrophy and disease of the liver originate in a morbid condition 
of the heart ; this is a very frequent cause of hepatic derangement. You 
have an example of it at present in the chronic ward, in the case of a 
poor man labouring under bronchitis of long standing, with disease of the 
heart, dropsy, and enlargement of the liver. In cases of this description 
it is a matter of some difficulty to determine in what organ the morbid 
sequence commences ; for where many diseases coexist, it is not easy to 
ascertain how they are related to each other as cause and effect. I have, 
however, had several opportunities of observing the progress of the dis- 
ease from the commencement, and the manner in which the different 
organs become successively implicated. 

Some time ago there occurred a remarkable example of this form of 
hepatic affection in a relative of mine, aged 14, who, in consequence of 
exposure to cold, was attacked with rheumatic inflammation of the 
joints of a very intense character. Owing to a want of proper care, 
the disease was allowed to go on unchecked, and metastasis to the peri- 
cardium took place. I happened to be out of town at the time, and he 
had no advice or assistance for nearly twenty-four hours. Pericarditis of 
a violent character became developed, and it was only by the most 
energetic treatment that he escaped with his life. He had pericarditis 
with effusion, and all the physical signs and symptoms of carditis. After 
the acute symptoms were removed, the signs of adhesion of the peri- 
cardium, hypertrophy, and partial valvular disease, continued ; and for a 
long time the heart's action was invariably accompanied by a long bruit 
de soufflet. These affections were followed by dyspnoea and increased 
action of the heart. But this was not all. He next got inflammation of 
the testicle, and finally chronic hepatitis with enlargement. The liver 
grew to a very considerable size ; it continued to enlarge for about seven 
months ; and altogether he laboured under a chronic form of hepatitis for 
more than a year. At last the disease yielded to treatment, and he reco- 
vered completely. 

This, you will say, was a fortunate termination ; but in young persons 
the powers of nature often act in a very remarkable manner in remedying 
or removing disease, and cures are sometimes effected in such patients 
which it would be quite absurd to expect in persons advanced in life. 
After having laboured under a long train of diseases, and having continued 
an invalid for nearly five years, this young gentleman at last, owing to 
his youth and favourable constitution, surmounted all his maladies, and 
is at present as strong and healthy as any person I am acquainted with. 
In this instance the chronic hepatitis was the result of the pericarditis, 
which formed the first link in the chain ; and for the space of a year this 
young gentleman continued to labour under an affection of the liver, the 
result of disease commencing in the heart. This is a morbid sequence 
very frequently observed. You have pericarditis, accompanied with 



ENLARGED LIVER FROM DISEASE OF THE HEART. 4S7 

inflammation of the lining membrane of the heart, partial disease of the 
valves, hypertrophy of the muscular substance, and then enlargement and 
induration of the liver. This is a very common complication, and 
deserves your most particular attention. When you see a patient whose 
appearance indicates disease of the heart — who has swelling of the face, 
dyspnoea, lividity of the lips, and turgescence of the cutaneous vessels — 
in fact, that peculiar expression of countenance which at once informs the 
practised observer that the patient is labouring under disease of the heart, 
you should not neglect to inquire after the condition of the liver, for in such 
cases it is very frequently in a state of chronic disease. I pointed out this 
circumstance some time since, in the case of a late surgeon, Mr. ML, and 
directed the attention of the medical gentlemen engaged in the treatment 
of the case to the liver, in which no one had suspected the existence of 
disease. Recollect, therefore, that in many cases of disease of the heart 
you will also, on examination, find disease of the liver, produced, as far 
as I can judge, in the majority of instances, by disease of the heart ; at 
least, I think I have never seen any case in which the hepatic affection 
had the initiative, and seemed to have brought on the organic affection 
of the heart. In Mr. M.'s case, and several others which I had an oppor- 
tunity of watching from the commencement, I have no doubt that the 
disease of the liver was secondary, and that the morbid sequence com- 
menced with the heart. I am quite convinced that disease of the liver may 
give rise to functional derangement of the heart ; for whatever impairs 
secretion and deranges digestion, will give rise to palpitations, tendency 
to syncope, and other phenomena of functional disease of the heart ; but 
I have never seen any example of organic disease of the heart as the 
result of disease of the liver.* 

It is of some importance to be aware of this complication ; for in treating 
the disease of the heart you must also attend to the hepatic affection, 
because it has a tendency to aggravate and confirm the cardiac symptoms. 
This affection, however, is not to be looked upon as acute, or even sub- 
acute hepatitis. There is scarcely any pain of the side or tenderness 
present, and the patient is not always jaundiced ; it appears to be scarcely 
any thing more than congestion, causing hypertrophy and chronic morbid 
growth. I shall not, however, speak too positively on the subject, as the 
difference between hypertrophy and inflammation of a low and obscure 
character cannot be easily determined. t 

There is another disease in which derangement of the liver is a common 



* [The disease of the liver is almost a necessary consequence of im- 
portant disorder of the heart. It probably results directly from the diffi- 
culty in the circulation, which of course tends to keep this organ turgid 
with blood. The disease is thus frequently almost mechanical, produced 
directly by the difficulty in the circulation, and cannot be removed unless 
its cause is susceptible of cure. The symptoms of this secondary disease 
are not always well marked, and its very existence is often not suspected 
until the fatal termination of the case. — W. W. G.] 

f I am glad to find that this subject has been taken up by so able an observer as Dr. Bright, 
who, in the third number of Guy's Hospital Reports, p. 605, has made some excellent remarks 
on the influence of heart disease in producing congestion of the liver. In Dr. Klliotson's 
Human Physiology, Part I. p. 103, there are some observations which throw much light on 
the intimate relation existing between the circulation within the chest and liver. 



4S8 CLINICAL MEDICINE. 

symptom, and I bring it forward chiefly for the purpose of rendering the 
subject under discussion more complete, as it is an occurrence well known 
to practitioners, and sufficiently dwelt on in medical books. T allude to 
that affection of the liver which is observed in cases of intermittent fever. 
Ague frequently produces a powerful determination to the internal organs, 
particularly the liver and spleen, and if treated badly, or unsuccessfully, 
is apt to bring on disease of the liver. The organ becomes congested, 
hypertrophied, and indurated, and presents a condition somewhat analo- 
gous to that which supervenes on disease of the heart, or results from the 
cachectic state of constitution produced by mercury or scrofula. • 

The next form of organic derangement which I shall briefly touch on, 
is that of the spleen. It is of advantage to place cognate affections be- 
side each other, for the purpose of comparison ; by doing so, we frequently 
derive many instructive and useful analogies. Besides, we have had a 
remarkable case of enlargement of the spleen in our wards at the same 
time we had the cases of hepatic disease to which I have alluded. I may 
observe, that the circumstances under which enlargement of the spleen 
takes place, differ in many points from those which determine hypertrophy 
of the liver. We have but few examples of inflammation of the spleen, 
while the cases in which enlargement and congestion of that organ take 
place are numerous. From the peculiarities of its anatomical structure, 
the spleen is very apt to become suddenly enlarged. Like the liver, it 
may become indurated and hypertrophied from intermittent, or from some 
general disease affecting the system, and thus lead to a train of secondary 
phenomena ; the most remarkable of which is dropsy. But there is one 
peculiar symptom attending enlargement of the spleen, which I have fre- 
quently pointed out to the attention of the class, as observed at least in 
two-thirds of the cases, and of which we had an excellent specimen in 
the patient under treatment in the chronic ward. The history of this 
symptom is the more curious as showing a remarkable uniformity in the 
phenomena of a particular disease at very distant periods of time. This 
is seen by comparing the most recent descriptions of Indian splenitis, as 
given in an able analysis of Voight's work on the Spleen, published in a 
late number of the British and Foreign Medical Review, and the descrip- 
tion of enlargement and disease of the spleen given by Aretseus. The 
ancients, it is true, cannot be now considered as authorities to be fol- 
lowed either in pathology or practice ; for they were ignorant of many of 
the most important facts connected with the healthy and diseased states 
of the human body. In consequence of their inaccurate anatomical 
notions, they were unable to appreciate or describe many of those details 
which now enrich the domain of pathological anatomy ; their writings, 
however, are invaluable in many respects, as containing admirable de- 
scriptions of diseases which still continue to infest the human body, and 
as recording certain groups of symptoms which are still associated. A 
comparison of their descriptions with those of modern times, cannot fail 
to be extremely curious, and may even prove highly instructive ; for if 
we find that certain internal affections have, from the most remote anti- 
quity up to the present period, been generally accompanied by peculiar 
derangements of distant parts, we are authorized in considering this con- 
nection to be something more than accidental, and consequently we may 
be led to discover relations between organs generally believed to be quite 
unconnected with each other. Thus, some years, I had three patients in 



ERYSIPELAS. 489 

succession under my care, who laboured under chronic enlargement of 
the spleen, who were all affected with a similar sort of cachexy, and had 
all the same affection of the skin — namely, superficial ulceration of the 
legs. This coincidence forcibly arrested my attention, and I was still 
more struck with the observation, on finding that Aretaeus had noticed 
this very circumstance in his admirable description of splenitis. " If" 
(says he), " the spleen does not suppurate, but becomes chronically en- 
larged, then the patients lose their appetite, and become cachectic, swol- 
len, and of an unnatural colour, while the surface of the body manifests 
a disposition to ulcerate, particularly on the legs : the ulcers are hollow, 
round, livid, sanious, and difficult to heal." This description agrees 
precisely with the cases to which I have already referred, and it coincides, 
in a very remarkable manner, with the account lately given by Dr. Voight, 
of chronic disease of the spleen, as it occurs in India. He observes, that 
the cachexy connected with the splenalgia Bengalensis frequently mani- 
fests itself by a tendency to ulceration ; the disposition to which is so 
great, that leech-bites and blisters occasionally give rise to foul or phage- 
denic ulcers, which, under certain circumstances, as where the patient has 
used mercury and is residing in a swampy district, will sometimes run 
on to a fatal termination. It is also curious, that the predisposing causes 
of the different varieties of chronic enlargement of the spleen, as given 
by Voight, are exactly the same as those detailed by Aretaeus ; and both 
writers correspond in their statements as to the age and habits of life of 
persons most liable to this disease, as well as the nature of the locality 
and the season of the year most favourable to its production. This agree- 
ment between authors separated from each other by so many centuries, 
and who describe the disease as it occurred in distinct regions, and among 
different races of mankind, is extremely curious, and exhibits a very 
remarkable example of the identity of the morbid phenomena produced by 
the same causes. 

So far of the pathological states of particular organs which arise in cer- 
tain conditions of the system, and most generally form a terminating link 
in the chain of diseased action. You will perceive that my observations 
are chiefly limited to a detail of the most important pathological observa- 
tions made in our wards during the preceding three months. After we 
have made a brief review of what has occurred during this period, we 
shall take up the consideration of the cases at present under treatment. 

The next disease which came under our notice so often as to deserve a 
separate notice, was erysipelas. There were some points of interest con- 
nected with the history of the erysipelas which prevailed in this hospital 
during the months of August, September, and October. In the space of 
somewhat more than two months, we had about twenty cases of this dis- 
ease; and, indeed, the morbific cause appears to be still lingering in our 
wards, though less frequently manifesting itself, for we have had only one 
case within the last ten days. Before, however, I proceed to notice the 
phenomena of the disease, as observed here, I shall make a few observa- 
tions connected with the treatment of this affection in general. I am 
anxious to direct your attention to this point, because the history of this 
epidemic has furnished some useful lessons, and has shown how much the 
treatment of any disease will depend on its epidemic character and exist- 
ing peculiarities. The disease was treated here in every instance, and 
through all its stages, with wine, quinine, and opium ; and, with the ex- 



490 CLINICAL MEDICINE. 

ception of a single case, this treatment has proved uniformly successful. 
Erysipelas, you are aware, is generally looked upon as an inflammatory dis- 
ease, and its treatment is always more or less antiphlogistic, particularly 
during the early stage. At this period, it is customary to treat it with 
general bleeding, leeching, scarifications, purgatives, mercury, and tartar 
emetic ; and I will allow that many cases should be treated in this man- 
ner. But the gentlemen who have attended this hospital within the last 
three months, have witnessed a form of erysipelas which required from 
the beginning an exactly opposite line of treatment. In the management 
of the cases which fell under our observation, no one in his senses would 
think of using general or local depletion, purgatives, or tartar emetic. 
The moment the disease appeared, we were obliged to attack it with tonics, 
narcotics, and stimulants. You perceive, then, that in erysipelas there are 
two very distinct extremes, between which there are many intermediate 
shades and varieties. It is well to bear this in mind. When you are 
called to treat a case of erysipelas, you should recollect that it is a disease 
capable of exhibiting a great variety of forms, amenable to no fixed line 
of treatment, and requiring for its management ail the sagacity and skill 
of an accomplished practitioner. I have seen many instances in which 
this affection appeared in a distinct and well-marked inflammatory form ; 
and I have treated cases with venesection, leeching, purgatives, and 
tartar emetic, and found these means admirably well fitted to remove the 
disease. Here, on the contrary, wine, opium and sulphate of quinine, 
were the only remedies on which we could rely with any degree of confi- 
dence. On the other hand, you will meet with intermediate cases in which 
these different modes of practice should be employed, either at distinct 
stages of the complaint and at a considerable interval, or should succeed 
each other by a rapid transition. Erysipelas, I must again repeat, should 
not be treated from its name. Many persons have maintained, that when 
gangrene supervenes on inflammatory affections, and among the rest, 
on erysipelas, that it is the result of an excessive degree of inflammation, 
and that it might be successfully combated by judicious depletion. This, 
however, is by no means generally true; and it is of importance that, in 
forming proper notions of the pathology and treatment of erysipelas, you 
should dismiss from your minds all preconceived opinions, and be regu- 
lated solely by the impressions derived from correct observation and facts. 
What I wish to impress upon your minds is, that gangrene may and does 
occur in cases of erysipelas quite independently of excessive inflammatory 
action, and requiring a plan of practice quite different from the antiphlo- 
gistic. I do not assert that gangrene does not arise in many instances 
from the violence of erysipelatous inflammation, and that in such cases it 
is to be met by prompt and decided antiphlogistic treatment, but I think 
your views of the pathology of this disease will be both imperfect and 
false, if you look upon the gangrene which frequently supervenes in ery- 
sipelas as the result of immoderate inflammatory action. The following 
case, which is one of extreme interest, will, I think, bear me out in my 
assertion. 

Mrs. B., a lady of middle age, was attacked with feverish symptoms on 
the 24th of last March. Notwithstanding the diligent employment of anti- 
phlogistic treatment by Mr. Barker, the pyrexia increased; in the course 
of a few days her throat became sore, and shortly afterwards erysipelas 
appeared on the face. Her case assumed a very dangerous aspect: she 



ERYSIPELAS. 491 

continued seriously ill for some days, and was saved with difficulty. On 
the 1st of April Mr. Carraichael advised the diligent application of fomen- 
tations, with the view of relieving the local symptoms; and her son, a 
young man of eighteen, of temperate habits, florid complexion, muscular 
frame, and who had always enjoyed a vigorous state of health, undertook 
the duty of applying the fomentations with much zeal and assiduity. To- 
wards evening, he thought, but without reason, that her case was hope- 
less, and fell into a violent paroxysm of grief, from which he was induced 
to rouse himself for the purpose of resuming his occupation of applying 
the fomentations. While thus engaged, he got, to use his own expres- 
sion, "a whiff of sickening air from the bed-clothes," and immediately 
felt unwell. This was on the 1st of April. On the second he was fever- 
ish, and complained of headache, for which he got aperient medicine, and 
was leeched. On the 3d there was no improvement, and he had passed 
the night without any sleep. On the 4th, Mr. Carmichael considered it 
necessary to leech the temples again, and to continue the exhibition of 
antiphlogistic and aperient medicines. He now began to complain of se- 
vere pain in the right shoulder, which at first appeared to be of a rheu- 
matic nature. He became more and more restless, and on the 7th of April 
was reported to have slept none for the three preceding nights. A very 
perceptible fulness was now observed under the right clavicle, extending 
down over the pectoral muscle; the parts were tender to the touch, but 
not red. Mr. Carmichael now examined the hand and arm of the same 
side with much attention, for the purpose of ascertaining whether any 
wound or injury had existed, for the symptoms seemed to resemble closely 
those produced by poisoned wounds. None, however, could be detected. 
The restlessness now increased to an extraordinary height; during the fol- 
lowing night the patient changed from one bed to anothei at least one hun- 
dred times, and the servants were incessantly employed in making and 
adjusting three beds, from one of which he wandered to another, impelled 
by an intolerable feeling of anxiety and uneasiness. During this period 
his bowels were free, his urine copious ; and though his fever was consi- 
derable, it was by no means proportioned to the nervous excitement, nor 
was it accompanied by delirium or pain in the head. The swollen parts 
of the trunk were leeched freely twice, and diligently fomented, and con- 
tinued to present the same appearance until the 10th, when a red patch 
appeared near the shoulder, subsequently spreading into a vividly red ery- 
sipelatous blush, which occupied the skin covering the pectoral muscle, 
and right axillary region. I saw him for the first time on the 11th. His 
pulse was 120, and by no means deficient in strength; skin hot, but 
covered with perspiration ; he did not complain of headache, but was quite 
sleepless, and excessively uneasy. His muscular strength was apparently 
not much reduced, and, indeed, until a few hours before his death, he was 
able to turn in bed with ease. His tongue was dry in the centre, and 
furred, but moist at the edges. The erysipelas was now spreading rapidly 
towards the left side, and down the front of the abdomen. An attempt 
was made, but in vain, to arrest its progress by the application of nitrate 
of silver to the skin around its margin, an operation which was performed 
with great care by Mr. Carmichael. Mercurial ointment was next applied 
to the inflamed surface, and although the erysipelas continued to spread, 
we were led to entertain some hopes of our patient, having succeeded, by 
means of tartar emetic, followed by opium, in procuring for him much, and 



492 CLINICAL MEDICINE. 

as he said , refreshing sleep. On the morning of the 13th, however, a black 
colour of the coriurn was observed in the situation of one of the bullae on 
his left side. This alarmed us; and in a few hours afterwards our suspi- 
cions were confirmed by the appearances of dark maculae in many parts 
of the erysipelatous surface. These livid patches spread very rapidly, and 
were in some places accompanied by effusion beneath the cuticle, but in 
others they appeared to consist in a mere change of colour in the external 
surface of the erysipelatous corium, without any detachment of the epider- 
mis. The patient took abundant nourishment, and got wine and cordials, 
but without any favourable effect. The scrotum now became engaged, 
and speedily assumed a gangrenous appearance. In some places the epi- 
dermis separated, and the gangrenous surface of the corium secreted sanies 
in large quantity, but in many parts no detachment of the cuticle took 
place. On the L4th, nearly the whole of the right side of the abdomen 
and the scrotum were superficially gangrenous, and the belly became tym- 
panitic. During this time apparently healthy feces were discharged in 
considerable quantity; the skin was covered with perspiration; the urine 
was copious and natural; and we had here, what is worthy of notice, 
seemingly healthy secretions from the bowels, liver, skin, and kidneys, 
co-existing with extensive gangrene of the surface. His tongue, however, 
continued dry and furred ; his restlessness unabated ; and the sleep pre- 
viously procured by means of opium now ceased, although that medicine 
was repeated in the same doses. His pulse also began to sink, but he re- 
mained quite sensible and free from delirium until immediately before his 
death, which took place on the evening of the 15th. During the latter 
days of his illness he had sweated copiously, and there was nothing re- 
markable in the odour of the perspiration. I may also observe, that the 
pulse likewise furnished but very fallacious indications ; for I can assert 
with truth, that six hours before his death, though soft and compressible, 
it still possessed a steadiness and a volume by no means calculated to im- 
part a suspicion of his approaching dissolution. His strength was also 
such as would lead to an erroneous conception of his real danger: for, as 
I have before observed, he was able to turn in bed shortly before his death. 
This observation is borne out by other cases, in which persons with ex- 
tensive gangrenous erysipelas, and in imminent danger, have been known 
to be capable of walking about. 

The evidently contagious nature of the erysipelas in this instance, and 
the youth and previous good health of the patient, render this case suffi- 
ciently remarkable. It is likewise worthy of notice, as proved by the 
circumstances, that the gangrene did not originate in the excessive vio- 
lence of the cutaneous inflammation, for it did not appear in those por- 
tions of the skin which were primarily and most violently affected. On 
the contrary, we observed that the parts which became gangrenous had 
been paler and less tense than those which did not assume that condition, 
and that the portions of the skin which died, were those which had be- 
come engaged at the latter stage of the disease. This is of importance ; 
for, combined with other facts, it forms an obvious refutation of the 
opinion not long since maintained, that gangrene and sphacelus are in all 
inflammations the result of immoderate inflammatory action, and conse- 
quently to be averted by antiphlogistic treatment only. In many instances, 
this opinion, and the treatment founded on it, are, no doubt, judicious ; 
but that there are cases in which the gangrenous tendency supervenes on 



GOUT — CONSTITUTIONAL INFLAMMATION. 493 

inflammation, or, in other words, is superadded to the inflammatory pro- 
cess, but independent of its intensity, no one will deny who candidly 
weighs the details of the case which I have just related, and recollects 
that the conclusions deducible from them have of late received too fre- 
quent a confirmation from the rapidly fatal progress of putrid sore throat — 
a form of cynanche which has reappeared in Ireland, after having almo>t 
disappeared for upwards of twenty years. In both cases the disease ap- 
pears to be infectious, and in both the gangrene seems to be quite inde- 
pendent of the intensity of the inflammation. 

This is a question so important in a practical point of view, that I shall 
make no apology for detaining you, as I am anxious to impress upon the 
minds of my younger auditors, that there are certain forms of disea>e 
termed inflammatory, in which the ordinary treatment by depletion is quite 
inadmissible. 



LECTURE XXXIX. 

GOUT. 



On constitutional inflammation in general — on fugitive swellings and pains — Curious case of 
erratic gout causing transient swellings — Gout affecting the lobe of the ear — Fatty hyper- 
trophy of the ears — Gouty grinding of the teeth — Gouty ' eoralgia of the skin — iU marks 
connected with Dr Kingston's researches on consumption — On paralysis in general — On 
paralysis depending on affections spreading from the extremities of the nervous system to its 
centre — Gouty ramollissement of the spinal marrow, two remarkable cases of — History of this 
hitherto undescribed form of the disease — Gout may affect the spinal marrow — Combination 
of arthritic inflammation with bronchitis — Effects of various remedies, particularly mercury 
— Effects of this in chronic bronchitis — Dr. O'Beimes's plan of rapid mcrcurializaiio:i in 
certain affections of the joints — Application of the same method to inflammation of the lungs 
of a scrofulous character — Cases in illustration. 

I take the present occasion of making a few remarks on certain varieties 
of gout, of which I have recently seen several singular examples, pre- 
mising some observations on constitutional inflammation in general. 

There is no proposition in pathology better established than that there 
exist certain constitutional affections capable of generating and modifying 
local inflammatory action ; and that local inflammations, depending on a 
constitutional cause, are subject to very different laws from those which 
regulate the phenomena of common inflammation. 

Another fact of equal importance in many points of view, is, that local 
inflammations depending on a constitutional cause differ remarkably from 
each other, and in general present specific characters easily recognized. 
Thus, local affections arising from scrofula are not likely to be confounded 
with those depending on gout or rheumatism, and the inflammations pro- 
duced by syphilis and other animal poisons exhibit peculiarities by which 
their respective origin and nature may be satisfactorily ascertained. It 
must, however, be admitted, that although advanced considerably in our 
knowledge of the phenomena of local disease depending on a constitu- 
tional cause, the subject still displays a wide field for investigation, and 
many points of much importance in pathology and practice require still 
further investigation. Professor Cayol, in his Lecons Orales, has made 
some observations on this subject well worthy of attention. Speaking of 
the dependence of local disease on constitutional causes, he says, " II faut 



494 CLINICAL MEDICINE. 

necessairement conclure que les degenerations organiques tie sont pas cause, 
mais effet. Et deslors, nous somraes fondes a vous dire, qu'au lieu d'user 
votre vie a chercher toujours quelles sont les degenerations organiques et 
les alterations de texture qui produisent les symptomes des maladies, il 
serait bien temps de s'inquieter un peu de savoir ce qui produit ces deg - 
nerations elles memes, en etudiant serieusement les caraeteres, la marche, 
et la tendance des actes vitaux qui les preparent, et qui les produisent 
reelment." 

There is one fact connected with local inflammation depending on a 
constitutional cause not sufficiently noticed, namely, that certain affections 
of this kind are sometimes remarkably fugitive and transient. . We are 
accustomed to regard the process of inflammation, whether common or 
specific, as one which generally lasts for some day's ; but it occasionally 
happens, that a peculiar diathesis will give rise to local affections having 
the characters of inflammation, and which run their course and terminate 
in the space of a few hours. This observation, which should be borne in 
mind in the investigation of diseases connected with the general habit, 
will serve to explain some of the anomalies which strike us occasionally 
in the study of constitutional maladies. The first instance of this kind 
that came under my notice occurred in the case of a florid healthy-looking 
boy, aged six years, in whom, on attentive examination, . I was led to 
suspect the existence of a scrofulous taint. At the time I saw him he w r as 
subject to a sudden and rapid formation of bumps, or tumours, on various 
parts of his body ; sometimes on the arms, sometimes on the legs, and 
occasionally on the trunk. These circumscribed tumefactions were accom- 
panied by a feeling of heat and tenderness, and apparently depended on 
local congestion, or effusion in the subcutaneous cellular tissue. But what 
was most remarkable in them was, they arose, ran through their course, 
and terminated in the space of four or five hours ; they were suddenly 
developed, and disappeared with equal rapidity. In the course of a 
month, other more permanent inflammations were set up ; scrofulous 
ophthalmia, glandular swellings, and ulcers supervened ; the joints be- 
came affected, and the boy died in about a year and a half, with all the 
characteristic marks of the scrofulous diathesis. I have detailed this case 
before, and shall not dwell on it any farther at present ; but it is well 
worthy of notice, in consequence of the very brief duration of the first 
local affections. 

Gout is another disease which occasionally exhibits examples of its 
peculiar inflammation attacking various parts and tissues of the body, and 
that for an extremely short period of time. It is well known that persons 
of a gouty habit are subject to sudden pains or twitches, which last only 
for a few minutes, or even seconds. I shall not stop here to consider what 
may be the nature of these fugitive pains ; I may observe, that certain 
facts seem to prove, that these pains are the result of a momentary con- 
gestion. Thus in various neuralgic affections, and in inflammatory dis- 
eases in which the nerves are considerably engaged, pain is suddenly 
produced by coughing. If a man labours under neuralgia of the frontal 
or facial nerves, or if he be affected with sciatica, how are his sufferings 
increased when he has unfortunately at the same time a cough ! Every 
time he coughs, the affected nerve gives notice that it feels the congestion 
by a sudden pain. Now t the only way in which coughing can increase a 
local pain, is by favouring local congestion ; that it is capable of doing 



gout. 495 

this is proved by the redness of the fare it occasions, as also by the he- 
morrhage from the nose, or from recent wounds, which is so often pro- 
duced by a fit of coughing. 

As there can be no doubt, then, that a momentary congestion may pro- 
duce a momentary pain, we may infer that in many instances gouty 
twitches are owing to some cause which determines an instantaneous 
congestion of the affected part. Sometimes the congestion is more last- 
ing, and then the pain is proportionally intense and persistent. Thus Mr. 
Daly, of Henry-street, knows a gentleman, the lobe of whose ear is some- 
times attacked suddenly by gouty congestion, accompanied by agonizing 
pain, but which never lasts more than a few hours. 

This fact brings to my mind a curious case which some years ago came 
under the notice of the Surgeon-General, Mr. O'Ferrall, and myself. A 
young gentleman of fortune perceived that the pendent lobs or tips of his 
ears were becoming elongated ; they increased gradually in such a man- 
ner that he considered himself disfigured by their unseemly length, and 
therefore attempted their concealment by allowing his hair to grow in 
long curls, so as to hide the ears. This gentleman soon afterwards be- 
came dropsical and died ; and, on dissection, Mr. O'Ferrall found his 
liver in a state of fatty degeneration. On slitting up the elongated por- 
tion of the ears, he discovered that their hypertrophy had been occasioned 
by the deposition of a large quantity of fat. The subcutaneous adipose 
tissue, and the omentum, were likewise much loaded with fat. This ob- 
servation is of some importance, as teaching us that fatty degeneration 
may be the consequence of a general tendency in the system to manufac- 
ture and deposit fat in the textures of the different organs. Id this point 
of view the change of structure in the liver must be regarded as an effect, 
and not as a cause, of the general derangement of the system, and the 
fatal termination of the case. 

One of the most remarkable instances of fugitive inflammation affecting 
various parts of the body, which has come under my notice, occurred in 
the person of a gentleman lately under my care. I shall not go through 
the whole history of his disease, of which he has favoured me with a very 
minute account, but shall merely state, that he is of a gouty habit, has had 
an attack of gout in :he stomach, and is at present subject to a gouty 
affection of a very extraordinary character. After labouring for some 
time under languor and weakness, accompanied by spasms, pain, and 
sense of weight in the stomach, the pain of the stomach ceases, and his 
face begins to swell at various points, generally commencing on the fore- 
head, and involving the cheek and eye, so as to close up the latter. He 
first feels as if a small current of air was directed on the face ; then, as it 
were, the fillip of a finger, or the bite of a gnat ; and, on looking in the 
glass, he suddenly perceives a tumour rising on the forehead, which, in 
the space of half an hour, becomes as large as a pigeon's egg, and, as he 
expresses it, moves down until it closes the eye. Sometimes it attacks 
his lips, and other parts of his face, but never affects his nose. These 
tumours have also appeared on various parts of his body ; and he observes 
in his letter to me, that he is sometimes led to think that they attack his 
stomach also. Before and during an attack of the face, which generally 
occurs on the left side, the discharge from the nostril of the affected side 
ceases. But what is chiefly remarkable in this case is, the singular cha- 
racter of the local affection. The tumours arise, run through their course, 



496 CLINICAL MEDICINE. 

and disappear, in the space of a few hours ; and on the following day 
there is no trace of their existence. Sometimes the lips, inside of the 
mouth, palate, and uvula, are attacked, giving rise to very considerable 
inconvenience. Were such tumours to occur in the neighbourhood of the 
glottis, 1 need not say that they would be pregnant with danger of no or- 
dinary character. I may observe, that this gentleman has derived great 
benefit from the use of hydriodate of potash, and from decoction of sar- 
saparilla with nitric acid, and that his health is at present much improved. 
His case presents a very curious example of transient local inflammation 
depending on the gouty diathesis. 

Having touched on the subject of anomalous local affections as con- 
nected with the gouty habit, I may be allow T ed to refer to a subject on 
which I have already published some observations. 

In a paper inserted in the Dublin Med. Journal for March, 1836, 1 noticed 
the morbid habit which some individuals have of grinding the teeth, and 
detailed some facts in illustration of this affection. I have now seen 
several cases of this kind, and 1 have observed that they all occurred in 
persons of the gouty diathesis. The grinding of the teeth continues for years 
as a daily habit, and produces very remarkable changes in the conformation 
of these organs, affecting sometimes one side of the jaw, sometimes both ; 
so that in confirmed cases we frequently find the teeth ground down to the 
level of the gums. There is not at present the slightest doubt on my mind, 
that the irritable state of the dental nerves, which gives rise to this irresisti- 
ble tendency to grind the teeth, depends chiefly on the existence of gout in 
the constitution. I may observe, however, that in many persons in whom 
the teeth are found w T orn nearly to the gums, there appears to be another 
cause in operation. Thus, in cases of indigestion it is not unusual to find 
the enamel of the teeth partially or considerably worn away, long before 
the natural time ; and in such instances we used formerly to attribute the 
injury to the generation of acids in the stomach. The researches of 
Donne and Thomson, however, have shown that the saliva is subject to 
very remarkable alterations in certain forms of dyspepsia, and that when- 
ever the disease is accompanied by much irritation of the gastric mucous 
membrane, and derangement of its secreting functions, the saliva becomes 
extremely acid, and, of course, capable of corroding the enamel of the 
teeth. The following case has recently come under the notice of Mr. 
Pakenham, of Henry-street : — 

A gentleman, aged 45, slightly made, but muscular, and born of 
healthy parents, was attacked with shivering and loss of power of the 
right side after a severe wetting. He recovered under appropriate treat- 
ment ; but, about a year afterwards, began to observe in himself a ten- 
dency to grind his teeth, which gradually increased to such an extent as 
to prove a nuisance to himself and every one about him. Under these 
circumstances he consulted an eminent surgeon in Dublin, who applied 
the actual cautery behind one of his ears, slightly affected his system 
with mercury, and extracted one of his teeth, — all with considerable 
relief, which lasted for about six months. He then became as bad as ever, 
and applied to another surgeon, who tried iron in every form without 
success : and subsequently to a third practitioner, who used in addition 
leeching, blistering, pustulation with tartar emetic and various other 
remedies, but without any favourable result. All this time his medical 
attendants, so far from suspecting the presence of gout, ridiculed the idea 
of its existence. 



GOUTY NEURALGIA. 497 

About three months ago, this gentleman came to Dublin, went to dine 
at the house of a friend, and with some others, supped late at night, and 
drank some whiskey punch. Next day he had vomiting, purging, and 
epigastric tenderness, and on the day after the ball of his great toe became 
swollen, hot, and exquisitely painful, leaving no doubt as to the nature 
of the affection. In this gentleman's case the grinding of the teeth is not 
constant, but it is always greatest when the stomach is most deranged. 
The teeth in the under jaw are all sound : three or four of the molars of 
the upper jaw have been extracted. The four upper incisors are ground 
nearly half way through to the gum on the inside, while the lower are 
very little worn. By pressing the tongue against the upper incisors, or 
by touching a certain point of one particular tooth, he can at any time 
arrest the tendency to grind, and can suspend it as long as pressure is 
continued in the manner just described. 

With the view of further illustrating the varieties of gout, I shall detail 
the following remarkable case, which came recently under my notice : — 
The patient, a gentleman of large fortune, is of a strong and athletic frame, 
about five-and-thirty years of age, and a member of a family subject to 
goat. He was much addicted to field sports, and accustomed, in cold 
weather, to frequent immersion of his feet in cold water, in pursuit of his 
favourite amusement, snipe-shooting. The consequence of this exposure 
has been, that he has been labouring for some time under a neuralgic 
affection of the lower extremities, which commenced in his feet and 
ankles, and extended gradually upwards, involving the whole of the 
lower extremities as far as the hips, and giving rise to sufferings of a very 
intense character. In a lecture formerly published, on Creeping Paralysis, 
I noticed, that repeated exposure of the feet to cold seems often to lay the 
foundation of this disease. Now in this case there is some danger that 
the gentleman, were proper measures neglected, may ultimately become 
paraplegic, or even generally paralytic. I do not bring this case forward 
as an example of gouty pains gradually advancing from the extremities 
towards the spine ; for although I strongly incline to the opinion that his 
complaint is of a gouty nature, and although most of his medical advisers 
have suspected a gouty complication, still this is by no means a decided 
point.* Be this as it may, his case presents a very interesting specimen 
of creeping neuralgia, chiefly affecting the cutaneous nerves (nerves 
exclusively destined to perform the function of sensation), but gradually 
implicating the nerves of motion in the disease. I shall now proceed to 
lay before you the details of this case, which have been noted with sin- 
gular accuracy and ability by the gentleman himself. In a letter to me 
he observes : — 

u As you wish for a description in writing of the manner in which I 
am affected, I subjoin every particular I can think of which seems likely 
to throw any light on the subject. 

" It is now nearly five years since I began to suffer severely from pains 
in my limbs, which for the last two or three years I have looked upon as 
neuralgic. About a year previous to that time I had occasional pains in 
one foot, which increased so as to become violent on one occasion, after 
a long ride. I had, however, been always in the habit of riding, and 

* I have since seen his usual attendant, Dr. Little, of Sligo, one of the most experienced 
and skilful physicians in Ireland, and am much gratified by finding mat Dr. Little's opinion 
exactly agrees with mine, as he considers the case to L>e gouty neuralgia. 

33 



498 CLINICAL MEDICINE. 

considered that exercise to agree particularly well with my health. In- 
deed, I had found hunting of great use to me, when suffering from liver 
complaint, having had inflammation of the liver twice in my life. It is 
now fourteen years since I had the last attack of liver disease, and I very 
seldom have pain in my side ; whenever it occurs, it is generally removed 
by the use of a little blue pill. 

" When first the pains in my limbs commenced, they were confined to 
my feet ; then, for a long time, extended no higher than my knees ; lat- 
terly they have ascended as far as my hips, where, and in the groin, I 
sometimes experience great suffering. I have had occasional twitches in 
my arms, and very slightly across the chest. The pain always comes on 
with sudden violence, which renders it very hard to bear, especially when 
it attacks me during sleep. I am frequently aware of its approach, from 
a general feeling of discomfort and depression ; from which, in the begin- 
ning of my complaint, I used to suffer very much for two or three days 
before an attack. These paroxysms have, for four years, shown a great 
tendency to periodicity, recurring generally once every week, commencing 
on Saturday or Sunday, sometimes on Friday, and lasting till Monday. 
They have twice or thrice lasted for a week together, but sometimes con- 
tinue only a few hours. In the commencement I have occasionally been 
free from them for two or three months together ; and within the last year 
was free from them, at two different periods, for a whole month. When 
in pain, I have never experienced the slightest alleviation from any thing, 
except at times from a full meal with wine, particularly champaign. I 
have often been unable to remain in bed, from the violence of the pain, 
which is increased by the weight of the bed-clothes, or the slightest touch 
of any thing ; even the air blowing on the part brings on violent torture : 
at the same time I can bear strong pressure, or even a blow on the parts, 
without making me worse. The pain appears to be quite on the surface, 
except that sometimes it seems deeply seated, particularly in the ankle- 
joint and shin bone. It is unaccompanied by any redness or swelling, 
and flies instantaneously from one limb to the other, rarely occurring in 
both at the same time. It leaves behind great weakness of the affected 
limb, so as to oblige me to walk with a stick for some time, and occa- 
sionally with two. 

" One very unpleasant consequence of the pains in my limbs is, that I 
now find I cannot use exercise on horseback, if I leave it off for anytime. 
I have found this and walking at all times conducive to my general health. 
Indeed, I can still walk a good deal, even during an attack, although it 
is very painful, particularly when setting out. I find it necessary almost 
constantly to have recourse to aperient medicine — generally rhubarb pill. 
At times ( have had giddiness of my head, and noise in my ears, to a 
very distressing degree:; and have had recourse to powerful purgatives, 
and even bleeding, to remove the symptoms, without effect. A medicine, 
principally nervous, in which gentian was an ingredient, relieved me at 
one time, after finding the above remedies ineffectual. I have already 
tried iron, mercury, nitro-muriatic acid, stramonium, arsenic, and the ex- 
ternal use of croton oil, without benefit, except that I felt rather better for 
a month after two of these remedies, but no longer, and the pain returned 
with great violence at the end of that period. The counter-irritation ap- 
peared to increase my sufferings. I have also tried anodyne embrocations 
without effect. Anxiety of mind, or annoyance, often brings on an attack. 



gout. 499 

I even remarked, the other day, that it came on instantaneously, on 
breaking a tooth whilst eating. On the other hand, excitement, whether 
from a sudden necessity for exertion, as on occasion of an accident, or 
any thing that gives a pleasing interest and occupation to my mind, such 
as travelling through an interesting country, seems to keep off, and some- 
times even remove an attack." 

In general, a regular attack of gout in the extremities is preceded by 
a longer or shorter period of constitutional disturbance and dyspepsia. 
We must not, however, in making the diagnosis between gout and rheu- 
matism, consider this distinction as not liable to exceptions, for I have 
seen more than one case of hereditary gout, in which the arthritic attacks 
came on suddenly, without the slightest precursory derangement of the 
health, or the operation of any assignable cause. I have as yet seen no 
instance of a similar nature in acquired gout. 

Another exception to the general rule is also worthy of notice. In 
general, a fit of the gout is preceded and accompanied by a scanty secre- 
tion of turbid, high-coloured urine. As the fit goes off, the urine in- 
creases in quantity, becomes clearer and paler, and loses its tendency to 
deposit the lithates and purpurates. Now, in two cases of hereditary 
gout, I have seen this order reversed, and the approach of the fit an- 
nounced by a great increase in the secretion of urine, which was quite 
watery and limpid, and continued so until the violence of the articular 
inflammation began to decline. The urine then became scanty, and de- 
posited the lateritious and pink sediment in great abundance. 

That the gouty diathesis may excite its specific inflammation in most of 
the tissues of our organs, is a fact generally admitted ; but I regret to 
state that our knowledge concerning the effects which it produces in these 
various tissues, is far from being accurate or extensive. Beere, M'Kenzie, 
Middlemore, and others, have done much towards elucidating its effects 
on the eye and its appendages ; and we are tolerably well acquainted 
with its progress in serous, synovial, and fibrous membranes. What 
changes it produces in the secretions of mucous membranes, is a question 
which has not been studied with an attention commensurate to its im- 
portance. Thus, though all acknowledge the existence of gouty cough or 
bronchitis, the diagnosis and history of this affection are still very incom- 
plete. This has been acknowledged by Dr. Stokes, who has published 
by far the best account of bronchitis which has yet appeared.* The 
effects of gout on the lining membrane of the urethra and bladder are 
better known and studied, but I think that much still remains to be done 
in this as in every other class of inflammatory diseases where the inflam- 
mation depends upon a constitutional taint. 

In my published iectures I have long since expressed an opinion at 
variance with that generally taught concerning the bronchitis and pneu- 
monia which accompany pulmonary consumption, and I have brought 
forward strong reasons for believing that too much importance has been 
attached, and attention too exclusively devoted, to the tubercles in this 
disease. Thus authors talk of tubercular pneumonia, where it would be 
more correct to designate the affection as scrofulous pneumonia accom- 
panied by tubercles; they speak of tubercular cavities and abscesses in 

* See a treatise " On the Diagnosis and Treatment of Diseases of the Chest," bv W, 
Slokes, M.D. This work places its author among the first medical observers of the day, mid 
has acquired for him a European fame. 



500 CLINICAL MEDICINE. 

the lung, in cases where scrofulous cavities and abscesses exist. In fact, 
I repeat it emphatically, that the essential characteristics of phthisis pul- 
monalis are derived from scrofula. This it is which converts what would 
be common into consumptive pneumonia or bronchitis ; this it is which 
so often renders both incurable. 

Tubercles and tubercular infiltration are mere results of nutrition mor- 
bidly modified by scrofula ; they are effects, not causes : they often exist 
without scrofulous inflammation, and the latter may exist without them. 
It gives me much pleasure to find that these opinions, which I published 
many years ago, have received ample confirmation from the observations 
of Dr. Kingston, in a paper read before the Royal Medical and Chirur- 
gical Society of London, and shortly noticed in the Medical Gazette, 
April 29, 1837. 

In pursuing the subject of my lecture, I shall now turn to the conside- 
ration of some phenomena connected with the gouty diathesis which 
possess a much deeper interest, and lead to views of far greater import- 
ance. I mentioned before, that we frequently observe flying-pains, or 
twitches, in various parts of the body, arising from a rheumatic or gouty 
cause ; that in some instances these affections appear to be limited chiefly 
to the nervous trunks or branches, and that we have thus what may be 
termed gouty or rheumatic neuralgia. We are familiar with rheumatic 
and gouty sciatica, and we know that the history and termination of this 
form of disease often prove it to be inflammation of a specific character, 
chiefly confined to the trunk of the sciatic nerve. Now it is not unrea- 
sonable to suppose that this specific inflammation of a nervous trunk or 
branch, may, like other inflammations, extend farther, so as to involve 
parts of more importance to the economy. What I wish to draw your 
attention to is this — that in certain cases, where gout attacks the nerves, 
giving rise to gouty congestion or inflammation, frequently recurring, and 
acquiring increased strength and deeper root as it proceeds, the morbid 
affection may, after years, or even months, run on until it reaches the spi- 
nal cord, involving a certain portion or portions of that organ, and pro- 
ducing loss of sensation and motion commensurate to the amount of spinal 
derangement. This is by no means an anomalous occurrence ; it is merely 
an instance of disease originating in the periphery of the nervous system, 
passing along the trunk of the affected nerve with a retrograde motion, 
and finally reaching the central parts. I have already pointed out this 
peculiarity in many affections commencing in the periphery of the nervous 
system, and showed how the disease extends gradually until it reaches 
the spinal cord, giving rise to various forms of paralysis. It is too much 
the custom to look upon paralysis as depending upon original disease of 
the nervous centres. I have proved that, very often, disease commencing 
in the nerves of some particular part or organ, may be gradually propa- 
gated to the spine, producing all the symptoms which are referable to an 
original affection of the nervous centres. In my lectures on this subject, 
I have brought forward numerous facts in proof of the propagation of dis- 
ease from the circumference to the centre of the nervous system ; and the 
pathological deductions I drew from these facts seem to me to include all 
the physiological discoveries made byMuller and Marshall Hall, concern- 
ing what the latter terms the reflex function of the spinal marrow. In 
these lectures I showed that enteritis, arising suddenly in two young and 
healthy persons, from indigestion and obstruction caused by an error in 



GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 501 

diet, was followed in both by well-marked paraplegia. T instanced, like- 
wise, examples of paraplegia connected with stricture of the urethra, and 
which were relieved by curing the stricture ; and I detailed cases of acute 
and chronic affections of the uterus and kidneys, which had entailed on 
the patients, as a remote consequence of the original disease, loss of the 
power of motion in the lower extremities, sometimes partial and curable, 
sometimes irremediable and complete. The cases I am about to relate 
form a most interesting and valuable addition to those referred to, and 
enable me to carry the principle then advanced still farther by proving 
that gouty inflammation of the nerves and their neurilema, may, in process 
of lime, extend to the spinal marrow and its investments, and give rise to 
derangements of the latter, terminating in ramollissement and structural 
degeneration. 

The subject of gouty degeneration of the spinal cord has not been 
alluded to distinctly by any author with whom I am acquainted, and is, 
as far as I can learn, quite new. The deductions, therefore, which are 
drawn from my cases, must, of course, be subject to such modifications 
as may be derived from future experience, and must remain to be con- 
firmed by further observation. It has been long known that gout may 
attack the brain, and the existence of gouty paraplegia is well known by 
practitioners who have studied attentively the progress of arthritic affec- 
tions. Thus, in a case which I witnessed some time back, in consulta- 
tion with Mr. Kirby, he prognosed the supervention of paraplegia at a 
time when the indications of its approach could not have been discovered 
by any observer of less experience and sagacity. I have already stated 
that gouty affections of the brain have long been known, and I am not 
sure that some of the older authors may not have alluded to gouty affec- 
tions of the spinal marrow ; but as our knowledge of the peculiar state of 
the brain and spinal cord, termed ramollissement, is comparatively recent, 
and not dating with any degree of accuracy earlier than the works of 
Abercrombie, Roston, and other modern authors, it is obvious that any 
observations made by the older writers concerning gouty affections of the 
nervous centres, can have no distinct reference to this lesion. The con- 
nection, therefore, of ramollissement of the spinal cord with gout, may be 
considered now, for the first time, distinctly pointed out. As one of the 
cases which I am about to detail presented an example of the most exten- 
sive ramollissement of the spinal marrow on record, it would, on this 
account alone, be especially deserving of attention ; but its interest is 
increased tenfold when placed in juxtaposition with the second case, so 
as to exhibit, in a striking point of view, the close resemblance observa- 
ble in the march or progress of both, as well as the identity of the lesion 
discovered after death. 

Mr. , residing in the Island of Anglesey, was very much addicted 

to field sports, and, while thus engaged, would occasionally remain for a 
whole day without food. He was also very fond of angling, and has 
been frequently known to wade up to his waist in water for many hours 
together, during very cold weather. His general health was good, and 
his habits were abstemious. In 1825, when about twenty-five years of 
age, he had fever, attended with inflammation of the joints, and said to 
be rheumatic : some pain and stiffness, and an evident enlargement of the 
knee-joints, remained, after the other articular affections had disappeared ; 
these symptoms, however, yielded, in a few months, to rest and appro- 



502 CLINICAL MEDICINE. 

priate treatment. His health also improved greatly, and he had no com- 
plaint of any kind whatever until the autumn of 1828, when he had a 
slight attack of ordinary cholera, after returning from a shooting excursion. 
In the spring of 1832, he was attacked with pain in one foot, supposed to 
be of a gouty nature : this pain disappeared during a drive of fifteen miles 
in an open carriage, hut a certain degree of tenderness remained, and was 
always felt, more or less, in the part originally affected. He had a similar 
attack of pain and tenderness in the same foot in the following autumn. 
At the time when this attack commenced he was twenty miles from home, 
and observed that during his journey the pain became diminished as be- 
fore, and in a few days subsided altogether. In August, 1833, he had a 
similar, but much more severe attack ; the pain was much more violent 
than before, and both feet were affected. This, however, did not prevent 
him from following field sports as usual ; he went on horseback to the 
mountains to shoot grouse, and to this exercise, and drinking a bottle of 
wine, he attributed his speedy, or rather sudden, recovery from the pain 
in his feet. 

Hitherto we have seen a naturally strong constitution struggling suc- 
cessfully against exposure to cold, imprudent habits, and a most injudi- 
cious method of disturbing, or rather repelling, local inflammation depend- 
ing on a gouty diathesis. It is not easy to explain how it happened that 
driving in an open carriage, or riding over the mountains, so effectually 
cut short the paroxysms of gout in the feet : but it is enough to know 
that the fits were suddenly and imprudently arrested, to be prepared for 
the consequences which ensued — viz., an irregular distribution of the 
gouty effort, and its determination to internal organs. 

In September, 1833 — that is, about a month after the sudden subsidence of 
the last attack — he was seized with a violent colic, accompanied by obstinate 
constipation. The pain was very severe, but he suffered more from a gene- 
ral feeling of restlessness (a restlessness beyond belief, as he expressed 
it) than from actual pain. He was also greatly annoyed by singultus, 
and was jaundiced after recovering from the attack of colic. In a lecture 
already published, I have mentioned some cases of jaundice supervening 
on arthritic affections : in such instances, I am inclined to think that it 
depends on rheumatic or gouty hepatitis. In January, 1834, he had 
another attack of colic, preceded by a fit, the precise nature of which I 
was unable to ascertain. As these abdominal attacks frequently occurred, 
I shall give a description of one of them, as communicated to me by Dr. 
Llewelyn Jones, jun., his attending physician, a gentleman who justly 
enjoys a high reputation in his profession. " A dull, wearing, and fixed 
pain would attack the patient in the region of the colon : this pain was 
not increased by pressure, and was accompanied by nausea, occasionally 
by vomiting, and always by obstinate constipation. These symptoms 
were attended by a most distressing sensation of restlessness and anxiety. 
They lasted on one occasion for three days and nights before I could get 
the bowels opened, when they were immediately mitigated. The pulse 
was never quickened, and in general remained natural ; but if the attack 
was prolonged, it became weak. There never was any fever, or any 
well-marked indication of inflammation in the abdomen. These attacks 
were always preceded or followed by a gouty affection of the feet." 

The attacks in the stomach and bow T els recurred frequently, and always 
with the same symptoms, until August, 1835, when a visible tremour of 



GOUTY RAMOLLISSKMENT OF THE SPINAL MARROW. 503 

the fingers became observable : during some preceding attacks he used 
to complain of weakness of the wrists and pains in the fingers, particularly 
the last joints. As the disease progressed, these pains became more in- 
tense and extensive, and the torture he felt in the hands and arms was 
beyond description. After August, 1835, he began to lose the use of his 
arms, the tremours increased, and he began to complain of stiffness about 
the neck, with great restlessness and anxiety. The abdominal attacks 
came on occasionally, but not so severely as before. The arms became 
gradually weaker, until the loss of muscular power was complete, and 
they were greatly emaciated ; but Dr. Jones, who had the patient under 
his observation until August, 1836, could not detect any evident diminu- 
tion, either in the upper or lower extremities, and the intellectual faculties 
remained perfectly unimpaired. In October, 1835, two months after the 
state of the upper extremities had indicated the approach of paralysis, the 
lower extremities became similarly engaged : they were affected with 
tremours and weakness, and in the following December the patient had an 
attack of violent pain, with swelling and increased heat in the ball of one 
foot, which was pronounced to be of a distinctly gouty character. After 
each attack of pain in the feet, as I have been informed by this gentle- 
man's sister, the loss of power in all his limbs increased, and if he gained 
a little strength in the intervals between these attacks, a recurrence of the 
paroxysm always made him worse than before. 

In February, 1836, I went to Anglesey to visit this gentleman, and 
saw him in consultation with Dr. Jones and Dr. Williams of Denbigh. 
After a minute examination of the history and symptoms of the case, I 
declared it to be my opinion that a gouty inflammation had attacked the 
nerves of the extremities, and had finally extended to the spinal cord and 
its sheath. I said, that at an earlier period of the disease I would have 
advised salivation by mercury, but as that was inadmissible under the 
existing circumstances, we should have recourse to other measures. I 
forgot to state, that from the commencement of the disease, the advice of 
Sir B. Brodie and other eminent practitioners in London had been ob- 
tained by letter. 

It would be useless to detail the various general and local remedies 
fruitlessly employed in this gentleman's case. He went to Liverpool in 
August, 1836, for the benefit of further advice ; but finding no relief, re- 
turned to Denbigh, where he died in the ensuing October. For some 
time before his death he was greatly emaciated, and quite paralytic in all 
his limbs, but retained his intellectual faculties to the last. His body was 
examined by Mr. Williams, whom I had met in consultation in the pre- 
ceding February. This gentleman informs me, that the viscera of the 
thorax and abdomen were healthy and normal, that no derangement or 
lesion of the brain could be detected, but that the spinal cord, opposite to 
the last cervical and first dorsal vertebra?, was softened to the consistence 
of thick cream ; the remainder of the cord was also softer than natural, 
but did not present any thing peculiar in other respects. 

In a letter which I have since received from Mr. W T illiams (to whose 
kindness I am much indebted, and to whose zeal and professional skill I 
can bear ample testimony), he expresses himself with regard to the nature 
of the patient's disease, in a way which confirms the views I have taken. 

He observes — " I once saw Mr. in an attack of the gout in the feet, 

about three years before his death. There was much pain, and a decided 



504 CLINICAL MEDICINE. 

gouty blush. Exposure in fishing and shooting to a very imprudent de- 
gree, while under the influence of these gouty attacks, I have no doubt, 
did much to render the disease irregular and erratic." 

The fact that the tremours and loss of power commenced in the arms 
two months before indications of paralysis of the lower extremities ap- 
peared, is sufficient evidence to prove that the spinal marrow was not the 
point from which the diseased action proceeded originally ; for had this 
been the case, an affection of this organ, sufficiently violent to give rise to 
paralysis of the upper extremities so gradual in its progress, and so well 
developed, must long before this period have occasioned paralysis of the 
legs also. There is a striking analogy between the progress of the tre- 
mours and paralytic symptoms in this case and in cases of painter's colic ; 
and the analogy likewise holds good as to the violent spasmodic affection 
of the bowels, and the constipation observed in both. It is further wor- 
thy of notice, that in painter's colic the nervous affection is accompanied 
by pain and weakness of the extremities, and ultimately, although long 
after the commencement of the disease, by spinal tenderness, — a fact 
which has been already noticed by Dr. Bright. Again, in painter's colic, 
as in the disease which I have just detailed, the affection of the spinal 
cord, and the consequent paralysis, are evidently subsequent to the dis- 
ease of the peripheral portion of the nerves. 

The next case, which I shall now proceed to detail, is one of equal 
interest and importance. A gentleman of robust frame, aged about fifty- 
five, and having an hereditary predisposition to gout, to which his father 
had been a martyr, and which had exhibited itself in one of his sons at 
the early age of thirteen, consulted me on the 7th of June, 1836. Being 
a man of extensive landed property, he resided chiefly in the country, and 
w T as in the habit of using much active employment and exercise, but in- 
dulged rather freely in the pleasures of the table. After suffering much 
annoyance from dyspeptic attacks, and various premonitory symptoms, he 
had a regular paroxysm of gout in the spring of 1828 ; he had a similar 
one in 1830, and another in 1832, each occurring, as before, during the 
spring season, and remarkably severe. During the year 1832, he had 
several slight returns of the complaint, and in January, 1833, had an 
alarming attack of an enteritic character, accompanied by spasms of the 
stomach and acute pain of the extremities. In the autumn of 1834 he 
suffered greatly from a nephritic affection, and got relief after passing a 
considerable quantity of uric acid gravel. In the spring of 1835 he had 
a fall from his horse, and for some time afterwards complained of pain in 
the small of the back and around the trunk. He recovered, however, 
and during the summer and autumn of that year remained pretty well ; 
but in the last week of December caught cold, which was followed by 
severe cough, and pains in the chest and feet : the latter were then con- 
sidered to be the effects of gout. From this period, his health, though 
often apparently restored, was never firm : he became subject to sudden 
attacks of pain, particularly in the chest, which gave him much uneasi- 
ness. On the 3d of June he consulted a physician in his neighbourhood, 
to whom he described his ailment as u a slight pain in the right side, 
which troubled him only a short time before he got up in the morning ;" 
this he stated he had felt occasionally for two months before. A very 
careful examination was made over the situation of the liver, the place 
in which he said he felt pain, but no tenderness or swelling whatever was 



GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 505 

detected, nor was there any in the direction of the spinal cord. His pulse 
was at this time perfectly regular, his bowels natural, and no dyspeptic 
symptoms existed. He used, by the advice of this physician, tonic- and 
laxative pills, and a stinfulant embrocation. 

When he consulted me on the 7th of June, 1836, I found him labouring 
under what appeared to me to be pleurodynia of an intermittent and gouty 
character. During the day he was perfectly free from pain, but in the 
evening the pain commenced, and continued with violence until morning. 
It is unnecessary to detail here the various local and constitutional reme- 
dies which I employed in this gentleman's case, but without any favour- 
able result. From the middle of June his symptoms became worse ; during 
the first part of the night his pains were very severe; towards morning he 
usually obtained relief by lying on his face, and carefully avoiding all 
motion. About the latter end of July, the pain, which had been almost 
constantly felt at the right side, moved to the left, imparting at one time 
the feeling as if a spear were passing through the diaphragm, and at ano- 
ther resembling the sensation as if these parts were squeezed in a vice. 
When he was in the horizontal position this pain was accompanied by a 
sense of weight; and at times the pain would shoot upwards to the clavi- 
cles, producing tenderness of the intercostal spaces. When the diaphragm 
was free from pain, it most commonly attacked the postero-inferior edges 
of the scapula, and the dorsal region in its vicinity. In August he tried 
the use of the warm bath, and found temporary relief from the first he took ; 
he remained too long in the second, which was heated to the temperature 
of 100, and nearly fainted. He used the warm bath six or eight times, 
but found no material benefit from it, and could not bear the pain produced 
by the jolting of his carriage in going thither. About this time there was 
a visible alteration in his gait and figure: the left shoulder was elevated, 
his whole frame attenuated, and his face pale; he had nearly lost all power 
of bending the spine, and walked with a peculiar stiffness of gait, as if his 
arms were pinioned. On the morning of the 21st of August he stated that 
he had suffered great agony during the night, and on its abating, conside- 
rable tumefaction was observable under the right ribs. Dyspeptic symp- 
toms now became urgent, his urine scanty and turbid; he became melan- 
choly, and his mind was wholly occupied with sad presentiments. At my 
recommendation he came to town, in order to place himself under my more 
immediate observation, and to have the benefit of a consultation. About 
the 30th of August he got, to his great joy, an attack of gout in both feet ; 
while this lasted, which was for about six days, he had complete relief 
from the agonizing pains in the diaphragm and chest. The interval of 
tranquillity was, however, but of brief duration; the inflammatory affection 
of the feet suddenly subsided, and the pain attacked the diaphragm with 
increased intensity. His strength, which had been rapidly failing, now 
gave way, and he became quite paraplegic. About the 10th of Septem- 
ber the abdomen became engaged, without any alleviation of the thoracic 
symptoms, and he began to complain of constipation, tympanitis, and ab- 
dominal tenderness. The mucous membrane of the bladder became next 
affected; he had retention of urine, with great irritation of the prostate 
gland, and it was necessary to draw ofFthe water with the catheter several 
times in the day. This state continued from the 22d of September to the 
10th of November, when the sphincter of the bladder became paralyzed, 
and the urine drained off* as fast as it was secreted. During all this time 



506 CLINICAL MEDICINE. 

the urine continued to present the characteristic marks of the lithic acid 
diathesis in an extreme degree, and contrasted strongly with the secretion, 
furnished by the inflamed mucous membrane of the bladder, which con- 
sisted of a greyish or whitish yellow, viscid, and somewhat puriform mucus 
containing either a free alkali, or an alkaline carbonate. This secretion 
was extremely adhesive, and hung down in long ropy filaments when the 
vessel in which it stood was inverted. The nature of this mucus was such 
as to prevent any reaction from taking place between its own alkali and 
the acid of the urine. The coexistence of two secretions in the bladder, 
the one alkaline and the other acid, as observed in this case, is extremely 
curious. 

In this way the patient's sufferings went on every day increasing, and 
requiring the most extraordinary care to produce any alleviation, a task 
which was discharged with the most indefatigable humanity and attention 
by Mr. Richardson, of Sackville-street, to whom I am indebted for most 
of the details connected with the earlier history of this case. About ten 
days before his death, the extremities, upper as well as lower, and the 
trunk, became quite paralytic ; and from the cervical vertebrae downwards, 
all power of motion and sensation was lost. His voice now became weak 
and inarticulate, deglutition was greatly impeded, and he finally sunk on 
the 27th of November, 1836. 

It may be necessary to state, that at the time the paraplegia was be- 
ginning to seize on the extremities, the patient was much annoyed by 
occasional involuntary jerkings of the weakened limbs. This morbid 
action of the voluntary muscles continued when all power of voluntary 
motion had completely ceased. 

This gentleman's body was examined twenty hours after death, by Mr. 
Adams. The body and limbs were greatly emaciated, and there were 
several sloughing sores on various parts of the body and limbs, particu- 
larly over the scapulae, sacrum, and ilium. The brain was perfectly 
healthy, with the exception of a slight effusion under the arachnoid, and 
into the fourth ventricle. On opening the spinal canal, which was done 
with extraordinary care and accuracy, the spinal marrow, from the fourth 
cervical vertebra down to its dorsal termination, was found converted 
into a morbid mass, of an ash-grey colour and pulpy consistence. The 
theca was quite healthy ; but on the first transverse section of it a great 
quantity of yellow serum flowed out, emptying at the same time the fluid 
contained in the fourth ventricle of the brain. When the medulla spi- 
nalis was slit from above downwards, various shades of colour were no- 
ticed on the surfaces of the sections. Opposite to the third dorsal vertebra 
a blackish colour prevailed ; and from this downwards a yellowish hue 
was noticed. Two little tumours, about the size of filberts, were found 
attached to the crura of the fourth dorsal vertebra ; these, as Mr. Adams 
remarked, were in all probability merely accidental formations. The 
bladder was very much thickened in all its coats, and was so contracted 
that it could not contain more than three ounces ; its internal surface was 
of a dark green colour approaching to black. The ureters were also 
thickened, the kidneys enlarged, and their lining membrane of the same 
dark colour as the bladder. The pelvis and infundibula of the kidneys 
were dilated, and contained a reddish diseased urine, with some puriform 
matter, the odour of which resembled that of the urine passed during the 
three weeks previous to his death. The other viscera did not present 
any thing worthy of remark. 



GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 507 

In order to understand the nature and progress of a disease like this, 
which travelled in a retrograde direction along the nerves and their sheaths 
to the spinal marrow, it may be well to point out some of the more strik- 
ing phenomena by which it is characterized. In the first place, the long 
continuance of the pains at one side of the body only, is in itself a de- 
monstration that the disease was then situated in the peripheral extremities 
of the nerves, and not in the spinal marrow ; for it has been well observed 
by Ollivier, that inflammation of the spinal marrow or its sheath can never 
remain confined to one-half of either for more than a very limited period. 
Indeed, so narrow is the cavity in which these parts are contained, and 
so intimate is the connection of their constituent parts, that it is quite im- 
possible for inflammation to remain more than a few hours, or at most a 
day or two, confined to either side. 

Some facts connected with disease of the spinal vertebne, and the pains 
accompanying the progress of that disease, may appear to contradict this 
view of the subject ; for in vertebral caries pains are often felt at one side, 
or in one limb — nay, they often cease, or seem intermittent. Now in 
order to explain this we have only to recollect that here the inflammation 
does not commence in the spinal marrow or theca, but in the bones, and 
that the nerves, after their exit from the spinal cord, are affected in all 
cases before the cord itself. The reason is obvious ; the affection of the 
nerves is secondary, and solely derived from their proximity to the in- 
flamed bone and investing tissues ; and consequently the nerves on one 
side may be affected, while the corresponding nerves on the other side 
escape for the time, and until the disease in the bone extends itself to 
their neighbourhood also. This view of the subject has not escaped the 
notice of German pathologists. 

In the case above related the pains continued in one side for months, 
and were then suddenly transferred to the other, an occurrence which is 
quite irreconcileable with the idea of their dependence on primary spinal 
disease. The well-marked ease the patient experienced when the gout 
appeared in the feet, and the perfect intermissions of pain which he fre- 
quently enjoyed during the earlier stages of the complaint, afford strong 
evidence that the pains, however violent and excruciating they might 
have been during the paroxysms, did not depend on an original affection 
of the spinal cord. Had the fall which this gentleman received, or any 
other injury, induced inflammation of the spinal cord, and subsequent de- 
generation of structure, the order and course of his symptoms would have 
been very different, and long intervals of comparative ease would not have 
intervened between the appearance of the first pains and the subsequent 
paralysis. 

When paraplegia originates in disease of the spinal cord itself, retention 
of urine, or irritability of the bladder, often announce the approach of the 
disease long before the loss of power in the limbs becomes evident ; whereas, 
in all those cases in which the paralysis creeps from the extremities along 
the nerves towards the spinal marrow, the bladder is affected only at a late 
period of the disease, as occurred in the case which I have just detailed. 
Finally, the remarkable similarity which exists, in various points, between 
this case and that of the Welch gentleman, who had never met with any 
accident or injury, and in whom a considerable degree of ramollissemenr 
was observed, leaves no doubt that in both instances the disease com- 
menced with gouty neuralgia, and inflammation of the nervous extremities 



508 CLINICAL MEDICINE. 

and their sheaths, which gradually extended to the central portions of the 
nervous system, and ultimately involved the spinal cord. 

It is of great importance that practitioners should be aware of this ter- 
mination, and know that in gouty habits the sad results already noticed 
may be produced, particularly as a knowledge of this fact may lead them 
to the timely adoption of preventive measures. Having experienced the 
total inefficacy of colchicum, hydriodate of potash, strychnine, and all the 
usual remedies, in relieving or removing this form of disease, I would be 
strongly inclined to recommend the early insertion of issues over the spine, 
with prompt and decided mercurializatian. Mr. Colles has recommended 
the use of mercury in paraplegia, and cites some cases in support of the 
utility of the practice. It is to be regretted that he has not given any 
hints as to the mode of diagnosing the cases likely to be benefitted by the 
mercurial treatment, from those in which mercury would be inadmissible. 
Hence his recommendation loses much of its value, and cannot serve as 
a guide to those who have to treat spinal disease connected with paralytic 
symptoms. It appears, however, sufficiently plain, that mercury, em- 
ployed at an early period of the disease, is most likely to prove servicea- 
ble where symptoms of paralysis arise from inflammatory affections of the 
nerves or their neurilema, or of the spinal cord and its sheath. 

So far at present on the subject of paralysis, as connected with the gouty 
diathesis. I hope to be able, at some future period, to bring it again be- 
fore you in a more complete and extended form. 

In the preceding observations we proved that gout often attacks the 
nerves of the extremities in the first instance, and then pursues a retrograde 
course until it reaches the spinal marrow. It is an acknowledged character 
of gout that it wanders from one organ to another, and that it is very un- 
certain as to the periods and duration of its attacks, sometimes appearing 
to have ceased altogether, again only to return with redoubled violence. 
These characters of gout are strikingly displayed in the two cases I have 
related, where it finally seized on the spinal marrow; and it is quite pos- 
sible that what took place towards the fatal terminations of these cases, 
may in other gouty subjects occur at a much earlier period, and without 
the previous occupation by the disease of the nerves of the extremities: 
indeed, there is no reason why gout should not attack the spinal marrow 
and its investing membranes in the first instance, or in consequence of me- 
tastasis. That rheumatism, the disease most closely allied to gout, may 
do so, has been proved by numerous examples, of which we owe some of 
the most striking to Dr. Copland and Dr. Prichard, for the result of whose 
researches on this subject I must refer you to the article Chorea, in Cop- 
land's Dictionary of Practical Medicine, where you will find that rheuma- 
tism not unfrequently produces both acute and chronic inflammation of the 
spinal membranes. These observations I make with the intention of 
proving that my views concerning gouty affections of the spinal cord are 
borne out by analogy, and the experience of others with respect to rheu- 
matism. 

The case of Coghlan, who has been for some time an inmate of our chronic 
ward, demands a few observations. He was admitted for an attack of 
arthritis on the 10th of December, and since that period has been subjected 
to various modes of treatment. You will recollect that on bis admission 
he stated that he had been attacked several times with rheumatic inflam- 
mation of the joints. Like most persons of his class, he has suffered greatly 



ARTHRITIC RHEUMATISM WITH BRONCHITIS. 509 

from repeated fits of illness, brought on by exposure to the same causes. 
One of the greatest misfortunes that can fall upon labouring men, is a severe 
attack of rheumatic fever accompanied by inflammatory affections of the 
joints ; it not only renders them helpless and useless for a considerable 
time, but also in some cases leaves them cripples for life, and in addition, 
the nature of their employment constantly exposes them to relapses, which 
at length bring on incurable affections of the joints; we have, moreover, 
in this young man's case, a combination not unfrequent in patients of this 
description, namely, the effects of cold on the chest as well as on the 
joints; arthritis combined with inflammation of the bronchial mucous mem- 
brane. Now where the arthritic affection is very severe, and accompanied 
by high fever, the addition of bronchitis is a great aggravation. Every 
time the patient coughs he feels like one stretched upon the rack; at every 
convulsive motion of the chest a severe pang is felt in every joint, and 
the ordinary rate of suffering is increased to positive agony. A case of 
this kind is often hard to be managed, even when the disease is recent 
and the constitution sound; but when you have to treat a severe attack in 
a person who has repeatedly laboured under the disease, and whose vigour 
has been consequently impaired, the difficulty is greatly increased. Here 
much attention is required on the part of the physician. Where the com- 
bination is met with in a primary attack, I am generally disponed to regard 
both affections as of the same character, and not requiring any difference 
of treatment; I therefore attack the arthritis and the bronchitis with the 
same remedies, that is to say, venesection, leeches 1o the affected joints 
and over the chest, and large doses of nitre and tartar emetic. These re- 
medies, however, are only calculated for the acute stage of a primary at- 
tack, and where the patient's strength is unimpaired; for when the disease 
is chronic, and debility present, you cannot venture on the use of large 
doses of tartar emetic and nitre. In such cases much benefit is derived 
from the use of colchicum, particularly where the patient labours under 
more or less fever. The following is the form which I am in the habit of 
using, and from which I have occasionally derived much benefit — 

R. Misturae Amygdalarum, ^viij., Aceti Colchici, 5s?., Acetatis Morphias, gr. i., Nitratis 
Potassae, gss. Sunint cochleare unum umpluin oinui vel secunda quaque hora. 

In Coghlan's case we tried this mixture with local applications to the 
joints and a blister to the chest, but found at the end of some days that 
there was no visible improvement in the patient. Now whenever a state 
of things of this kind occurs, no time should be lost ; for rely on it, that 
where colchicum does not afford relief til a short time, and in moderate 
closes, there is no use in giving it a further trial. You have here to con- 
tend with two affections of a very serious character — one capable of ren- 
dering your patient a cripple for life, the other threatening him with suf- 
focation, from an extension of the inflammation into the minute bronchial 
tubes, an occurrence which is most commonly followed by dangerous 
congestion of the lung. Under such circumstances, the only treatment 
you can adopt with a hope of speedy relief and ultimate success, is to lay 
aside all other remedies, and trust almost exclusively to the use of mer- 
cury. In cases of this kind do not hesitate a moment, but mercurialize 
your patient at once, if his constitution be at all capable of bearing it. 
The treatment which was followed in the case under consideration was 
this : — we gave the patient ten grains of hydrargyrum cum creta, four 



510 CLINICAL MEDICINE. 

times a-day ; and with the view of relieving pain and the irritation of the 
bronchial mucous membrane, he took one drop of hydrocyanic acid, and 
ten drops of tincture of hyoscyamus, in half an ounce of almond emulsion, 
three times daily. 

Permit me here, gentlemen, to direct your attention for a moment to 
the influence which mercury exercises over inflammatory affections of the 
joints, and over certain forms of inflammation of the mucous membrane. 
I, in common with most practitioners, look upon mercury as a most valua- 
ble remedy in the treatment of arthritic inflammation, and in certain forms 
of bronchitis, but I do not, however, advise its indiscriminate employ- 
ment, or bid you mercurialize every case of bronchitis or arthritic inflam- 
mation ; you can cure very many cases of both without mercury, and you 
should only have recourse to it in emergencies, of which I shall speak 
afterwards, and where other remedies have failed. In treating bronchitis 
in general, I always try bleeding, leeching, blisters, and expectorants, 
before I have recourse to mercury. But where these fail, and the disease 
continues to wear a threatening aspect, you will often find that mercury 
will cure it in a very rapid and surprising manner. You had an example 
of this in a boy who was lately under treatment in the chronic ward. He 
had severe laryngitis, with an extensive inflammation of the smaller bron- 
chial tubes, great dyspnoea, and considerable congestion of the lung, and 
you perceived that the moment he came under the influence of mercury 
all his symptoms were ameliorated. We gave the mercury originally for 
the laryngeal affection, but in giving it, remarked that it would also cure 
the bronchitis, and such was actually the case. Observe, I do not give 
mercury in bronchitis as a general rule, — it is often unnecessary, and even 
sometimes wholly inadmissible. I will except from this that severe form 
of bronchitis, with congestion of the lung, in children after measles, which 
is best treated with calomel and ipecacuanha, as recommended by Dr. 
Cheyne. Many children were lost by severe attacks of this form of bron- 
chitis, and by hooping-cough, accompanied by congestion of the lung, 
until Dr. Cheyne hit upon this simple but effectual plan of treatment. 
But in ordinary bronchitis of an acute character, and producing a tendency 
to congestion of the lung, I do not prescribe mercury until other means 
have failed. 

Now I believe every practical man is aware that mercury is one of the 
best remedies we can employ in many cases of acute and subacute bron- 
chitis, but perhaps it is not generally known, that even in some cases of 
chronic bronchitis, that is to say, where the patient labours under chronic 
catarrh, with asthmatic symptoms, not onl\ relief, but even a complete 
cure, is occasionally effected by the use of mercury. One of the first 
cases of this kind which struck me very forcibly, was under the care of 
Mr. Porter. The patient, who laboured under an attack of venereal 
laryngitis, had at the same time chronic bronchitis, with puriform expec- 
toration and hectic, and as the use of the stethoscope was not then w T ell 
understood, was supposed to be labouring under phthisis. From the 
violence of the laryngeal symptoms, however, Mr. Porter was obliged to 
give mercury, which not only arrested the laryngeal inflammation, but 
also cured the chronic bronchitis. I recollect, also, the case of an elderly 
gentleman, treated by Surgeon Mitchell, of Harcourt-street, for an attack 
of very long- continued chronic bronchitis, with asthmatic symptoms, and 
who was subject to paroxysms of coughing and violent dyspnoea, which 



MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 511 

sometimes lasted for twelve hours together. Now this gentleman, after 
the failure of various remedies, took mercury, and with the most marked 
and permanent relief of his pulmonary symptoms. I was, it must be con- 
fessed, greatly surprised by the effects of mercurialization in this case, and 
it was quite a novel thing to me to witness a chronic, a very chronic bron- 
chitis, with copious expectoration and frequently-recurring dyspnoea, ag- 
gravated so as to endanger life by the least cold ; it was, I say, novel to 
me to see a patient so affected radically cured by a mercurial salivation. 
Perhaps, however, nothing but the absolute refusal of the disease to yield 
to other remedies, could authorize the adoption of such a plan in the pre- 
sent state of our knowledge. 

This puts me in mind of a plan which I have adopted within the last 
six or seven years, in the treatment of certain diseases of the lungs, and 
on which I shall make a few observations, as it has not been spoken of 
by those who treat of the cure of pulmonary affections. I must here in 
justice confess that the idea of this plan of treatment is not solely mine, 
but was founded on an analogy derived from the researches and experi- 
ments of Dr. O'Beirne, on scrofulous inflammation of the joints. An 
extensive experience and deep reflection first led Dr. O'Beirne to think 
that the acute stage of scrofulous inflammation of the hip and knee-joint 
might be made amenable to active and energetic treatment ; in other 
words, that inflammatory affections of the joints, which terminate in some 
of the worst and most fatal forms of disease, viz., morbus coxa? and white 
swelling, might be checked in limine, and before the stage of hopeless 
ulceration was established. He therefore proceeded boldly and at once 
to try whether the disease might not be arrested in the commencement 
by rapid mercurialization. 

Observe, gentlemen, this idea was completely new, it had never 
occurred to any other person, and was diametrically opposed to the 
theories of the day. The prevailing opinion on this subject was, that 
mercury was inadmissible, and could only produce mischief in persons of 
the scrofulous diathesis. Every one said, do not give mercury in such 
a case, it exacerbates scrofula, it even brings on scrofula in many in- 
stances where there had been no appearance of it previously ; you can 
do no good with it, and may do infinite mischief. Dr. O'Beirne, how- 
ever, knew the difference between the proper and improper exhibition 
of mercury — between mercurializing the patient at once and fully, and 
then stopping, and the pernicious custom of giving long and irregular 
courses of mercury. He tried the remedy and succeeded, and the surgeons 
of Europe have justly appreciated the value and importance of his dis- 
covery. About two or three months before Dr. O'Beirne made his 
discovery public, I had translated for the Dublin Medical Journal, a paper 
from a German author on the use of corrosive sublimate in baths, in the 
treatment of white swelling, and Dr. O'Beirne states that the publication 
of this paper gave him courage at the time in pursuing a plan of treatment 
so much at variance with the opinions of the day. I published this paper, 
however, at the time merely as a curiosity ; it was a novelty in practice 
of which I had no experience, and could not offer any explanation. This 
was reserved for Dr. O'Beirne. He has shown in his memoir on the 
subject, that if you give mercury so as to affect the system rapidly you 
will frequently succeed in curing the disease, particularly in the com- 
mencement. 



512 CLINICAL MEDICINE. 

From this I was led by analogy to apply the same principle of treat- 
ment to incipient scrofulous inflammation of the lung, and I think I have 
often succeeded in checking at once this most formidable of human 
maladies. Phthisis, as every medical man knows, is capable of assuming 
a variety of forms, and presents at its origin much difference of aspect. 
In some, it arises slowly and insidiously, and the pulmonary symptoms 
are so quietly and gradually developed that it would puzzle an intelligent 
practitioner, who had the most ample opportunities of observing his patient 
from the beginning, to say at what 'particular period distinct evidence of 
danger had been noticed. The reason of this is because the tubercular 
affection of the lung is in such patients only of secondary importance, the 
disease which produced it having affected the whole system before the lung 
was contaminated. This happens in some, but in others an opposite train 
of phenomena is observed, and scrofulous inflammation commences in the 
lung before any general contamination of the system has taken place. 
It is in such cases, and such only, that mercury ought to be tried, and it 
will avail nothing except where the commencement of the scrofulous 
inflammation of the lung has arisen suddenly, and in consequence of the 
operation of some obvious cause, as catching cold or the occurrence of 
haemoptysis. I think that too much stress has been laid on the affectfon 
of the lung by writers on phthisis. In some cases (I will admit even in 
the majority of instances), the disease commences in the lung, but in 
others it passes through many changes, and affects various organs before 
it attacks the lung. You will frequently see persons labouring under 
scrofulous irritation, accompanied by hectic, emaciation, loss of appetite, 
and excitement of pulse, long before you can find any trace of tubercular 
deposition in the lung. I am of opinion that many persons would die of 
phthisis even supposing they had no such organ as the lung. 

But let us suppose the case of a person of scrofulous habit who gets an 
attack of fever, with local inflammation, and that this inflammation fastens 
on the lung. Take for instance the following case : a young man of 
robust and vigorous frame, but evidently of the scrofulous habit, who has 
laboured repeatedly under scrofulous ophthalmia in his infancy, and who 
has lost several members of his family by consumption, gets, we will 
suppose, a severe cold by overheating himself in walking into Dublin 
from the country on a damp evening. He is attacked next day with 
feverish symptoms and severe catarrh, which soon becomes a formidable 
bronchitis ; but the young man being of a vigorous habit and fond of com- 
pany, continues to go out and expose himself to night air, until at length the 
catarrhal fever is changed into hectic, the bronchitis into organic disease 
of the lungs, tubercles become developed, and the disease passes into 
phthisis. Here, you perceive, a man gets an ordinary cold, which 
becomes a bronchitis ; he neglects this, and it passes into disease of the 
pulmonary tissue and tubercular ulceration. Now this is a very common 
course of diseased action in persons of a scrofulous habit, and I have in 
many such cases been able to trace the fatal malady to a common cold 
exacerbated by neglect and bad treatment. You perceive I do not use 
the ordinary nomenclature of writers on consumption ; I do not recognize 
the terms " tubercular inflammation" as connected with cases of this 
description ; indeed, I am inclined to think that the whole theory of 
inflammation being excited in the lung by the presence of tubercles is 
founded on erroneous views. I have repeatedly found tubercles in the 



MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 513 

lungs of persons who died of other diseases, without any trace of inflam- 
mation around them, and I believe every pathologist will confirm this 
statement. From this and other reasons, I have been led to the conclu- 
sion that tubercles do not act in all cases as foreign bodies, and that the 
theory which attributes the origin of inflammation to their presence is 
wrong. In one of the preceding lectures, I have brought forward nume- 
rous arguments to show that we are in possession of a much truer and 
more intelligible pathological explanation of the fact in question. You 
may have scrofulous inflammation of the bronchial mucous membrane, or 
you may have scrofulous inflammation of the lung singly or combined, or, 
what is most frequently the case, you may have either or both accompanied 
by tubercular development. The development of tubercles, however, in 
a case of scrofulous bronchitis or scrofulous pneumonia, is a coincidence,, 
and not a cause ; and you may have either of those affections singly or 
combined, without any coexistent or preceding tubercular development. 
Most commonly scrofulous bronchitis and scrofulous pneumonia are con- 
joined ; the former seldom exists for any length of time without producing 
the latter, and the latter is usually attended by more or less derangement 
of the bronchial mucous membrane. 

But what I chiefly wish to direct your attention to on the present occa- 
sion (and it is a matter of the deepest importance) is, can we prevent the 
development of phthisis in a person of scrofulous habit who has caught 
cold, got a dangerous attack of bronchitis or pneumonia, and is threatened 
with hectic? I do not wish to enter here into any disquisition concerning 
the means to be adopted with the view of preventing tubercular deposi- 
tion, or producing absorption when tubercular matter has been deposited 
in the tissue of the lung. To prevent tubercular deposition you must cure 
the scrofulous diathesis if you can. But suppose you, are called to a case 
of the kind I have already described, wbere a young man of scrofulous 
diathesis gets a bad bronchitis or pneumonia, exacerbates it by neglect, 
and is threatened with hectic, what is the best plan you can pursue? My 
impression is that you should treat it as you would treat acute scrofulous 
inflammation of the knee or hip-joint; in other words, that you should 
mercurialize your patient rapidly and at once; do' it suddenly and decid- 
edly, but without pushing the mercury too far, and you will often arrest 
all the symptoms of the disease as it were by a charm. I could mention 
many cases which have been treated successfully in this w r ay. I was very 
much struck by the case of tw T o eminent medical practitioners who came 
to Dublin within this last year to place themselves under the care of Dr. 
Stokes and myself. One was a person of scrofulous habit, who had caught 
cold after taking mercury, and. neglected it for three weeks. At the time 
we saw him he laboured under severe and harassing cough, considerable 
lever and emaciation, and was greatly alarmed about his condition. He 
had been several times leeched over the trachea by Dr. Stokes, but this, 
although an admirable remedy in many cases of bronchitis, failed in pro- 
ducing an amelioration of his symptoms, and from the persistence of his 
feverishness, emaciations, and harassing cough, serious apprehensions were 
entertained that his disease would terminate in phthisis. Having explained 
to our patient our views of the case, and our impression that mercury was 
the only remedy on which we could rely with any hopes of success, we 
ordered him to confine himself to his room, continue the application of 
leeches to the trachea, and take mercury. Now T as this gentleman had 
34 



514 CLINICAL MEDICINE. 

come up to town under the impression that he was consumptive, we found 
some difficulty in persuading him to submit to this mode of treatment. He 
yielded, however, but with great reluctance. In the space of a week all 
his bad symptoms had nearly disappeared. As soon as he came under the 
influence of mercury the cough became notably diminished, and he re- 
covered flesh and strength with surprising rapidity. The other was a phy- 
sician from the north of Ireland, who w T as suddenly attacked by pulmonary 
apoplexy, and in a few weeks came to Dublin, harassed by a constant dry 
cough, which prevented sleep at night, and he was visibly emaciated and 
anxious. In him no hereditary tendency to phthisis could be ascertained, 
but nevertheless Sir Henry Marsh, Dr. Stokes, and I considered the case 
as very unpromising, for although there was no acceleration of the pulse, 
the breathing w T as easily disturbed, and we could detect crepitus and some 
dulness above the right mamma, where it was evident the original seat 
of the hemorrhage had been. This case, too, which had resisted a mere 
antiphlogistic treatment, yielded in a most satisfactory manner to mercury. 

Bearing these facts in mind, I think, gentlemen, you will be prepared 
to admit that mercury is a most valuable remedy in the treatment of scro- 
fulous bronchitis and scrofulous pneumonia — diseases w r hich too often re- 
sist the ordinary modes of treatment, and which are unfortunately so often 
followed by fatal disease of the lung. Where a sudden attack of cold has 
produced inflammation of the substance or lining membrane of the lung in 
;a person of scrofulous habit — where the attack is recent, and has occurred 
sunder circumstances which preclude any suspicion of previous tubercular 
disease — in such a case as this you will find mercury a most admirable 
remedy in checking symptoms often not amenable to other plans of treat- 
ment, and which if neglected or maltreated would in all probability end 
in phthisis. I was led to the adoption of this plan by the success which 
has attended Dr. O'Beirnes's practice in acute scrofulous inflammation of 
the joints, and from observing that cases of unmanageable chronic bron- 
chitis had been occasionally cured perfectly where mercury had been ex- 
hibited for other affections; and it is a curious fact that about the time I 
had fallen upon this mode of treatment, it suggested itself likewise to the 
minds of Dr. Stokes and Sir Henry Marsh, who can testify to its utility; 
of course it wiSl not succeed in all cases ; and I have seen it fail in others 
where I had confidently expected benefit. Notwithstanding this, it is a 
most valuable addition to our resources in certain cases that would end 
/in phthisis. 

About a year ago I attended a young gentleman, apparently of robust 
constitution, who died of phthisis ushered in by a frequent-recurring hae- 
moptysis. Shortly after his death, I w 7 as called on to visit the elder bro- 
ther of my former patient. He had a constant hard, dry, and very distress- 
ing cough, which deprived him of sleep, and having continued many 
weeks had produced a most formidable degree of emaciation. Consump- 
tion was naturally dreaded. His pulse, however, was normal, and the 
stethoscope did not indicate any pulmonary lesion; still, as the case had 
refused to yield to all the ordinary remedies, including change of air, we 
felt very apprehensive as to the result. I confined him to bed, applied 
leeches over the trachea several times, and rapidly mercurialized him, and 
with complete success. He has continued well ever since. 



MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 515 

Postscript. — Since the remarks on the use of mercury in some cases of 
incipient phthisis were published, I have continued to employ it in the 
class of cases then pointed out. It has also been adopted by others, 
amongst whom Dr. Munk must rank foremost, for the great attention he 
has paid to the action of this remedy in the disease in question. This 
gentleman's communication first appeared in the London Medical Gazette, 
from which it was transferred to the pages of the Dublin Medical Journal, 
for March and May, 1841. I shall here introduce the principal part of his 
memoir, which deserves great attention, from the zeal and ability with 
which the author has followed up the subject: — 

" Cases and Observations illustrative of the Mercurial Treatment of some 
Forms of Incipient Phthisis Pulmonalis, by William Munk, M.D., Phy- 
sician to the Tower Hamlets Dispensary. 

" The idea of employing mercury as a curative agent in the early stage 
of some forms of phthisis pulmonalis, occurred, we are informed, about 
the same time, and without any mutual communication, to Sir Henry 
Marsh, Dr. Graves, and Dr. William Stokes. The two latter of these gen- 
tlemen have laid before the public some of their earlier experience on this 
interesting subject. The first communication which appeared was from 
Dr. Graves, and is contained in his published clinical lectures, whilst the 
experience of Dr. Stokes will be found detailed in his excellent treatise 
on the Diagnosis and Treatment of Diseases of the Chest. The results of 
this practice in the hands of Sir Henry Marsh are not, so far as we know, 
yet before the profession. Dr. Corrigan, more recently, in a very interest- 
ing lecture, has pointed out the elass of cases, and the stage, in which this 
mode of treatment is inadmissible. 

[Dr. Munk quotes here from the preceding lecture, which we shall omit 
repeating.] 

" The results of this practice, as hitherto published, are as follows. Dr. 
Graves states in general terms, that he could mention many cases which 
have been treated successfully on this plan, and then proceeds to particu- 
larize three in which its action was manifestly curative. It failed, how- 
ever, in two cases in which he made the trial of mercurial treatment. In 
two of these a permanent recovery ensued ; in two, temporary, though 
well-marked relief, was experienced ; in one instance it was useless ; and 
in another, the medicine manifestly disagreed. Dr. Corrigan narrates but 
one case ; yet this is decidedly in favour of the treatment ; for the patient 
speedily recovered. Exclusive, then, of the experience of Sir Henry 
Marsh, who is reported by Dr. Graves to have found this mode of treat- 
ment beneficial, there are for reference twelve cases. In six of these a 
cure resulted, in two considerable benefit, in three it was useless, and in 
one the medicine disagreed. 

" Small as is this experience when numerically considered, and insuffi- 
cient as to the decision of a point so completely at variance with the doc- 
trines of the schools, it nevertheless appears to us, that the evidence 
above adduced, coming as it does from persons so well qualified to form 
an opinion on the subject, has attracted far' less of attention than its 
intrinsic importance legitimately demands. Out of twelve cases of a dis- 
ease so uniformly fatal as phthisis, there have, under a new and peculiar 
mode of treatment, been six cures. This will, probably, to many persons 



516 CLINICAL MEDICINE. 

be a startling assertion ; and I have, therefore, before making it, been 
careful to state distinctly from what sources the information has been 
derived. 

" On investigating the pathological condition to which the observations 
of the authors above quoted refer, we shall find, that conclusions as to its 
nature and seat must be based almost wholly on the general symptoms 
and general signs ; post-mortem examinations serving our purpose but 
little, inasmuch as few cases prove fatal at this period of its course. 
These circumstances combined, make necessary a large amount of observa- 
tions before any certain conclusions can be obtained ; and they tend, in 
no inconsiderable degree, to render doubtful to many members of the 
profession the opinions maintained by those who have given attention to 
the subject, whilst they no less cause the treatment pursued, and the suc- 
cess which is stated to have resulted therefrom, to be regarded with some 
degree of suspicion. This is, perhaps, but an illustration of that salutary 
caution which, within certain limits, should mark our conduct in reference 
to new views and novel modes of practice hence derived, more especially 
when, as in cases like the present, many of the arguments are deduced 
from negative, rather than from positive facts. 

" The form of disease now under consideration, very commonly attacks 
individuals in tolerable or even apparently perfect health ; although if 
their previous state be minutely investigated, it will, I believe, in such 
instances, be found that there exist more or fewer indications of deterio- 
ration of habit, in the shape of scrofulous cachexia — whether that be of 
hereditary origin, or has been acquired by error in some of the non-natu- 
rals. Its commencement is, in the majority of instances, sudden and 
well marked ; its immediate exciting cause clearly ascertainable, being in 
general owing to the application of some of the common causes of inflam- 
mation ; or it originates, as do other local inflammatory affections, during 
the course of fever, of the exanthemata, influenza, &c. The phenomena 
attending it are those which point to a lesion of the bronchial mucous 
membrane, pulmonary parenchyma, or, as is most frequently the case, the 
two combined ; that lesion being evidently inflammatory in its character, 
as evinced by pyrexia, and by the existence of the physical signs and 
general symptoms of bronchitis and pneumonia. 

" The disease, in its most frequent form, commences after the manner of 
a common catarrh. The- patient having been exposed to moisture, or a 
low temperature, often the two combined, experiences a sensation of chill- 
iness, which may augment to actual rigors. These are attended by lan- 
guor and indisposition to bodily or mental exertion, pains about the back, 
and aching of the limbs ; to which succeed heat of skin, increased fre- 
quency and strength of pulse, thirst, and a more or less unnatural appear- 
ance of the tongue. The respiratory organs evidence disorder; the voice 
becomes somewhat altered ; irritation is perceived about the larynx, giving 
rise to frequent, dry, and irritative cough. As the case proceeds, sore- 
ness is experienced beneath the sternum, a sense of tightness across the 
thorax ; more frequent cough, which either then, or within a short period, 
is accompanied by expectoration, at first of a watery, saline, and irritating 
character, but which soon mellows down into a clear, tasteless, viscid 
fluid, scanty in quantity, and expelled with some difficulty. In other 
cases the expectoration presents characters different from those just men- 
tioned ; it is more abundant, brought up with ease, and, in lieu of being 



MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 517 

clear and tasteless, is opaque, sweetish, and pus-like. These symptoms, 
individually or collectively, may be more or less severe ; they do not, in 
the majority of instances, arrive at such a height as to induce the indi- 
vidual to place himself at this period under medical care. The indispo- 
sition is looked upon as a common cold, perhaps more than ordinarily 
severe. Yet it is subjected at this time to domestic remedies alone. 
Should the practitioner, however, have an opportunity of examining a 
case at this period, he will find bronchitic rales over more or fewer parts 
of the chest, existing perhaps only, or at any rate greatly preponderating, 
in one or both lungs. After continuing for an uncertain period, these 
symptoms undergo modification ; some may altogether disappear ; but, in 
general, a diminution of severity is alone experienced. The patient 
hence flatters himself that he is improving ; but the speedy addition to 
the category of symptoms of no mean import, dispel the illusion, excite 
fears as to the indisposition, and cause him then to seek professional 
advice. There is emaciation and loss of strength ; the phenomena of 
common pyrexia merge into, or are changed for those of hectic, among 
the symptoms of which, rapidity of pulse and morning perspirations will 
be found the most marked. There is severe and harassing cough, with 
or without a viscid purulent expectoration, considerable hurry of respira- 
tion, shooting pains about the shoulders, disturbed and sleepless nights. 
The stethoscopic signs at this period consist of a minute and clear mucous 
rhonehus, more properly, perhaps, designated by the term muco, or sub- 
crepitant, and existing only in the superior portions of the lung. In other 
cases there is heard at this part of the chest a modification of the normal 
respiratory sound, which, when once distinguished, can never afterwards 
be mistaken, but the description of which in words, as of most other 
sensations, is a task of difficulty. The respiratory murmur is here some- 
what modified, scarcely if at all diminished in intensity, yet giving the 
sensation of being moister, as though the bronchial tubes were lubricated 
with more fluid than in their healthy state ; not, however, as it would 
seem, in sufficient quantity to produce the subcrepitant or mucous 
rhonchi. 

" In these instances we may occasionally, by very careful and prolonged 
examinations, detect at long intervals, especially on a deep inspiration, a 
solitary and minute mucous bubble. Here we generally find that expec- 
toration is exceedingly slight, or altogether wanting ; whilst in the cases 
presenting the subcrepitant or mucous rhonchi, expectoration does exist, 
although rarely to any great extent. Little or no information can be ob- 
tained from percussion during the earlier periods of the disease, the chest 
then sounding perfectly well. As the case, however, advances, more or 
less dulness is perceived ; and when this occurs, the active auscultatory 
signs undergo a corresponding modification. At first there is an increase 
in duration and intensity of the expiratory sound, giving to the whole re- 
spiration a sensation of greater roughness ; this increasing, passes onwards 
into well-marked bronchial respiration, coincident with which there is 
bronchophony and bronchial cough. It were useless to trace these cases 
further ; tubercular matter has now been deposited in considerable quan- 
tity, the case is one of confirmed phthisis, and the period for the employ- 
ment of mercury has passed. 

u Such will be found the commencement and course of many of the 
cases of phthisis which are amenable to mercury in their earlier stages. 



518 CLINICAL MEDICINE. 

Sometimes, however, the disease takes its origin in a severe and universal 
bronchitis, which at once calls for medical interference and for active 
treatment. There is here great feverishness, considerable embarrassment 
of respiration, and intense bronchial rattles over the whole chest. Gene- 
ral and local blood-letting, with tartar emetic, seem to be here clearly in- 
dicated ; and although it be found in the sequel that these measures are 
not so well borne as the symptoms would have led us to expect, still from 
their employment the patient derives considerable relief. The activity of 
the disease is broken, the fever is diminished, the respiratory oppression 
relieved, and the bronchial rales lessened both in intensity and in extent. 
The stethoscope indicates, however, that the morbid action still lingers 
within the lung, and that the superior lobes are the parts now alone af- 
fected. The remedies which had proved effectual in the removal of in- 
flammation from the other parts are powerless over these ; and their con- 
tinuance serves but to debilitate the patient, and to hasten on the disease 
to an incurable stage. The lesion here existing may, however, be re- 
moved, but its removal can be accomplished in no other way than by the 
employment of mercury, so as to produce its specific effects upon the con- 
stitution. If the mineral be not had recourse to, the case goes on from 
bad to worse ; percussion and auscultation evidence the deposition of 
tubercular matter within the lung, and incurable consumption is thus in- 
duced. 

" Another and not unfrequent mode in which this disease originates 
remains now to be noticed. Allusion is here made to those cases the 
commencement of which is distinctly traceable to some general disorder 
of the. whole system, as, for instance, essential fever, the exanthemata, 
influenza, &c. In the course of all these there is a great liability to con- 
gestions, determinations of blood and inflammation. The bronchial 
mucous membrane and pulmonary parenchyma become frequently affected 
in this manner, the supervention of such morbid state being, in some in- 
stances, proclaimed by symptoms so well-marked, that the lesion from 
whence they originate cannot be overlooked. In far the greater number 
of instances, however, the local disease is to a greater or less degree 
latent, the marks of general disturbance being so numerous and severe as 
to cast into shade or obscure the more feeble manifestations of low mor- 
bid action in the Jung. The former class of cases being at once recog- 
nised, are promptly met by appropriate treatment, the local disease is sub- 
dued, and the disastrous consequences to which it tends thus averted. 
In the latter instance, however, the local affection often goes unrecog- 
nised, and no measures are adopted for its removal ; or, if it be discovered, 
its severity is frequently underrated, and means employed which prove 
inadequate to the end proposed. In either case the phenomena are simi- 
lar to those before enumerated ; they indicate a low inflammatory action 
of one or more tissues of the lung, existing only in the top of the organ, 
or, if more extensively spread, greatly preponderating in these parts. 
Should this condition continue, the patient presents a like succession of 
symptoms to those we have described above as occurring when phthisis 
supervenes upon catarrh, modified, however, in some measure, by the 
nature and usual course of the disease in whose progress they have arisen. 
There is an analogous mitigation and modification of the local and gene- 
ral symptoms, together w T ith the addition of other phenomena dependent 
on the disordered state of the lung, and the disturbances in other organs 



MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 519 

to which its sympathetic relations give rise. The patient experiences 
what appears to be a long, tedious, and unsatisfactory convalescence. 
After a time he retrogrades considerably, and the symptoms of pulmonary 
disease come prominently forward. The efforts of the practitioner to re- 
lieve the condition of general disorder are set at nought by the local dis- 
ease, which proves an insurmountable weight to the resiliency of the con- 
stitution. Emaciation progresses, the symptoms of hectic appear, and 
after a time the physical signs testify the deposit of tubercle in the lung. 

" It may probably be urged by some that the term phthisis cannot with 
propriety attach to the lesion of the respiratory organs above described, 
inasmuch as the active and passive auscultatory signs differ widely from 
those commonly laid down by writers as indicative of this disease, and 
point only to low bronchitis or pneumonia. The justice of this objection 
we are forced to admit, if the term phthisis be employed in a limited 
sense, and as expressive only of those cases in which tuberculous matter 
has already been deposited within the lung. But regarding the subject 
in a practical point of view, we come to an opposite conclusion : for 
abundant experience testifies that the transition from the state above de- 
scribed to that of confirmed phthisis is gradual and progressive ; that in 
point of fact the condition now under consideration is neither more nor 
less than that which determines scrofulous deposition to the lung, whilst 
it is, at the same time, the very action by which this deposit is effected. 

" In the three cases above described, phthisis, from neglected though 
mild bronchitis — as the sequel of severe bronchial inflammation ineffi- 
ciently treated, or as ensuing upon bronchial or parenchymatous inflam- 
mation occurring during the course of other and general disease — there is 
found only a sibilant, clear, mucous, crepitant, or muco-crepitant rhon- 
chus ; these persist for a long period, and are, during the early stage, 
unaccompanied by other signs. The sonorous rhonchus is rarely heard ; 
the mucous exists in a diminutive form, approximating in character to the 
crepitant ; the expectoration but rarely undergoes the same rapid succes- 
sion of changes observed in pure ordinary bronchitis, but remains clear, 
tenacious, spumous, observing more the habitudes of peripneumonic or of 
bronchopneumonic disease. This combination of symptoms points there- 
fore more to the minute bronchial tubes as the seat of disease, than to 
either the larger tubes or the parenchyma. It presents much resemblance 
to that form of disease termed capillary bronchitis, but is attended by less 
expectoration than is usually found in this disease, when occurring in its 
more usual site, the lower portions of the lung. 

" Now if it be asked, says Dr. Stokes,* what gives these signs of bron- 
chitis their value as diagnostics of incipient tubercle, the answer is, that 
it is not by their mere characters (for these do not differ from ordinary 
bronchitis), but it is from their situation,! localization, and combination, 
with comparative dulness of sound, that they derive their value. The 

* " Treatise on the Diagnosis and Treatment of Diseases of the Chest, p. 392. 

f " Louis, says Dr. Cowan, has invariably found that the sibilant, mucous, and submucous 
rales resulting from simple catarrh, originate in the lower part of the chest, while bronchitis 
complicated with pulmonary tubercles is always situated in the upper lobes. Simple bronchitis 
usually attacks both sides of the chest, while rhonchus from tubercles is atjirst almost con- 
stantly confined to the upper lobe of one side. Of the immense importance of this law there 
can only be one opinion, and, in many instances, attention to the seat of bronchitis would 
dissipate much doubt and anxiety, and early indicate the real nature of an affection which, 
without the knowledge of this fact, would frequently be confounded with simple catarrh, and 
thus frustrate the hopes both of the patient and practitioner. 



520 CLINICAL MEDICINE. 

same phenomena scattered over, or even existing intensely throughout th< 
lung, but being equable, and unaccompanied by dulness, would not only 
have no value in the diagnosis of phthisis, but would render the existence 
of tubercle improbable. Simple bronchitis is seldom circumscribed, while 
that of the consumptive is commonly so : the latter begins in the upper 
portion of the lung, remains obstinately fixed in the air-tubes, gradually 
spreads downwards, and while in its first stages in the lower lobe is com- 
bined with tuberculous ulceration in the upper : it may be intense in the 
upper lobe while the lower is altogether free, or engage the whole of one 
lung while the other is scarcely affected. These are not the characters of 
ordinary bronchitis. 

" A new aspect has been given to the pathology of tubercular disease 
by the investigations of Sir James Clark,* Dr. Carswell,f and the late Dr. 
T. J. Todd, J who have proved that, for its production, a previous mor- 
bid condition of the system must exist : in other words that a necessary 
element in the causation of scrofula is a certain cachexia or abnormal state 
of the fluids of the body. In what this consists has been most clearly 
shown by Dr. Carswell, whilst the circumstances leading thereto have no 
less satisfactorily been elucidated by Sir James Clark and Dr. Todd. 
From the united labours of these gentlemen have resulted the important 
pathological law, that tuberculous matter exists as a morbid constituent of 
the blood, is eliminated from it by a process analogous to, if not identical with, 
secretion, and is thus deposited, in a visible form, in different organs or parts. 
" The contamination of the blood exists in some cases for a lon°- period, 
and proceeds to a great extent before the deposition of tubercle com- 
mences. It seems not improbable that in such instances the sanguineous 
fluid becomes so thoroughly saturated (if the phrase be allowable) that an 
attempt at relief is then commenced, and nature sets about the work by 
eliminating the morbid product in conjunction with the secretions. Dr. 
Carswell is of opinion that the surfaces of mucous and serous tissues are 
those upon which tubercular matter is chiefly deposited ; that as regards 
relative frequency the former very far exceeds the latter : for here, he 
says, ' as into the great emunctory of the system, it appears to be sepa- 
rated from the blood, and becomes visible to us under a variety of forms.' 
Dr. Carswell is at issue with most pathologists as to its deposition in the 
molecular structure of organs. In no one instance has he witnessed it so 
situated. Our own observations tend to an opposite conclusion, although 
we doubt not that the most frequent sites of tubercle are those pointed out 
by Dr. Carswell. We believe with most pathologists, that tubercular 
matter has no peculiar site ; that it may, under certain circumstances, 
appear in any organ or part of the body, making its appearance thereby a 
lesion of nutrition, whereby such matter is secreted in place of, or in union 
with, those molecules of the blood, which, appropriated to the organ itself, 
become an integral portion of its structure, and thus repair the losses it 
is ever undergoing. 

" This deposition is frequently a silent process ; it commences and 
proceeds to a certain point, unaccompanied by any known pathological 

* "Treatise on Pulmonary Consumption, Lond., 1835. 

f •« Art. Tubercle, Cyclop, of Practical Medicine, and Illustrations of the Elementary Forms 
of Disease. Fascic. Tubercle. 

* " Art. Indigestion, Cyclop, of Practical Medicine, and in Sir James Clark's work on the 
Influence of Climate, and Change of Air, &c. 



MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 521 

state, or, if phenomena of disorder do occur, they are to be regarded as 
effects or coincidences rather than as causes. It will probably be found 
that this relation obtains only in those cases where scrofulous cachexia, 
and the contamination of the blood, which is its essence, has proceeded 
to a considerable degree, and where the local deposit is the result of the 
overcharged condition of the blood, rendering relief by the elimination of 
some portion of the morbid constituent, indispensable. 

u In other, and, perhaps, the majority of instances, tubercle is deposited 
long ere the cachectic state has arrived at the degree above supposed. In 
these, such an event is determined by irritation or inflammation, under the 
influence of which there is a large afflux of blood to the part, and coin- 
cident with it an increase and modification of secretion. In lieu of the 
results of common inflammation, as occurring in a healthy subject, there 
is here deposited tubercle, or coagulable lymph variously modified, the 
modification consisting in the approximation of that product, more or less 
closely in character to tubercle. The analogy which exists between these 
two morbid products, and the mode in which one may pass into or give 
origin to the other, has been clearly shown by Dr. C. J. B. Williams. 
Its further consideration here would extend these remarks to an inconve- 
nient length ; I shall, therefore, content myself with referring those who 
may wish to enter fully on the subject to the third volume of the Library 
of Medicine, p. 166, et seq. 

" The close connection existing between irritation or inflammation in one 
or other of the tissues of the lung and tubercle, as cause and effect, has 
been particularly dwelt upon by Andral,* who enumerate the following as 
the principal morbid alterations accompanying the development of tubercle : 
first, hyperemia of the bronchia of a certain size; second, hyperemia of the 
air-cells and ultimate ramifications of the bronchia without obliteration of 
their cavities ; third, hyperemia of the same parts with considerable 
thickening of their parietes, and obliteration of their cavities ; fourth, an 
effusion of blood into the tissue of the lung ; the blood thus effused coag- 
ulates, becomes a living part, and secretes tubercle. f In reference to 
these pathological conditions he states that, in certain cases, and those 
not the least numerous, the morbid alterations of the lung were evidently 
prior to the formation of the tubercles, and contributed to produce them. In 
the Clinique Medicale there is a passage explanatory, in some respects, of 
that just quoted. In it the author alludes to the influence of bronchial 
inflammation as giving rise to tubercle ; but the explanation will, mutatis 
mutandis, apply with equal force to the same pathological condition else- 
where situated. * What ought never to be lost sight of,' says he, ' is 
this — that, in order that inflammation of the mucous membrane of the 
air-passages shall be followed by the production of pulmonary tubercles, 
it is necessary to admit a predisposition. This being admitted, we can 
easily conceive how, in one individual, very slight bronchitis is sufficient 
to produce tubercles, whilst others do not become phthisical from the 
most severe and long-continued pulmonary catarrh. 5 Sir James Clark 
also expresses his belief that inflammation in a tuberculous constitution 
may give rise to the deposition of tuberculous matter in place of coagu- 
lable lymph, which, in healthy subjects, is its natural product, and thus 
inflammation may be one of the immediate causes of tuberculous disease.^ 

* Pathological Anatomy, translated by Drs. Townsend and West, vol. ii., p. 553. 

•j- This opinion of the secretion of tubercle by the blood itself, M. Andral has since eschewed. 

* Op. ctat., p. 46. 



522 CLINICAL MEDICINE. 

" I have quoted these authorities at length, because I conceive that the 
recognition and just appreciation of the facts and opinions therein con- 
tained will have a most important bearing upon practice, and because 
each day's experience leads me to the opinion that cases like to these are 
far more numerous than is now generally admitted. The existence, in 
one class of cases, of inflammation within the lung, to be succeeded by 
the deposition of tubercle as cause and effect, is widely different from 
those in which an inverse relation obtains — where tubercular matter is 
first laid down, and inflammation follows either as consequence or coin- 
cidence. The causes determining tuberculous disease towards the lung 
are, in these instances, widely different ; in one it is well known, and 
within the reach of medicine ; in the other it is unknown, and the means 
at our command are comparatively inoperative. One class of cases are 
curable, though, from circumstances, not always cured ; the other are 
incurable, as regards medicine, though nature's efforts are, in a few rare 
instances, more successful. 

" As inflammatory action is in these cases the distinguishing character- 
istic, and throughout performs so important a part, it is but natural that, 
to its consideration, much attention should be given, and that its removal 
should be held as a canon of the first importance in our treatment. Blood- 
letting, either general or local, counter-irritants, emetics, digitalis, &c, 
the means which experience testifies to have been the most efficient in the 
treatment of phthisis, act principally by the removal or diminution of in- 
flammation, determination of blood, congestion, and the disordered move- 
ments in the system to which their existence gives rise. These measures 
are, however, rarely sufficient for the perfect cure of the pathological con- 
ditions above-mentioned, more particularly of the variety termed scrofu- 
lous, or the modification impressed upon inflammation by its occurrence 
in a scrofulous constitution. Highly important as auxiliaries, they must 
in no case be neglected, but as controllers of the disordered action of the 
capillaries, which constitutes inflammation, they are, in the majority of 
instances, inoperative. A medicine was wanting more potent in its 
effects, one whose action was evidenced not so much upon the central 
organs of the circulation as are blood-letting and digitalis, but on the 
periphery of the system, the capillaries. 

" Iodine and its numerous preparations have been recommended to 
public confidence, as a medicine calculated in some degree to meet this 
want. The action of iodine is manifested principally as a stimulant of 
the capillaries ; by giving tone to these vessels it expedites the circulation 
through them, obviates and removes congestion, and frees the secretions. 
It exercises little, if any control, upon the peculiar action, whatever it be 
that constitutes inflammation ; but after the removal of this state a degree 
of congestion commonly remains, and here iodine is most effectual. Re- 
liance must not, therefore, be placed on iodine in the class of cases and 
stage above described, although it comes in, as we shall show, with ex- 
cellent effects, at a somewhat later period of the treatment.* 

" It has, by abundant experience, satisfactorily been proved, that in the 

* There are peculiarities in the action of the analogous substance, bromide, which seem to 
point it out as peculiarly adapted to certain forms of scrofulous disease, especially phthisis. I 
am at this time making comparative trials with the bromide and iodide of potassium, the results 
of which, I hope, at a future period, to lay before the profession. Of its superiority in some 
forms of cardiac disease, I am already pretty fully convinced. 



MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 523 

treatment of common inflammation there are no means at our command 
which, in point of efficacy, will bear comparison with mercury. How- 
ever much pathologists may differ as to the proximate cause of this state, 
or writers on the effects of medicines to the mode of action of this mineral, 
they one and all agree in the truth of the above assertion. The know- 
ledge of this fact suggested to the mind of Dr. O'Beirne the employment 
of mercury in scrofulous affections of the joints. He regarded the inflam- 
matory action attending these cases as a point of primary importance, and 
to its immediate removal directed all his attention. The results of the 
practice he was thus led to adopt proved the correctness of his ideas, no 
less than the value of the measures upon which he relied, whilst the adap- 
tation of a like practice to those forms of phthisis during the earlier periods, 
of which inflammatory action is the predominant and all-important local 
condition, led to scarcely less successful results in the hands of Drs. Graves, 
Stokes, and Corrigan. 

" Mercury has heretofore been frequently proposed by distinguished 
authorities as a remedy in consumptive cases. It has never, however, 
acquired any great celebrity in the treatment of this disease ; the pro- 
posals and recommendations for its employment, whensoever or from 
whomsoever originating, appearing to have passed unheeded by the bulk 
of the profession, or if attended to or followed to have fallen short of the 
expectations which its too sanguine advocates had raised, and thus to 
have dropped again into disuse. Among those who have recommended 
mercury we may mention Dr. Rush, and other physicians, his contempo- 
raries in Philadelphia. A perusal of their writings will clearly substan- 
tiate the charge of what to us must appear indiscriminate practice — a fault 
less justly perhaps to be attributed to them than to the imperfect state of 
our science at that period. Upon no point in practical medicine were our 
predecessors more likely to run into error. The absence, until a very 
short period, of any correct information as to the precise nature and pro- 
duction of tubercle, the limited period during which mercury is in truth 
available, and the difficulty which existed, previous to the introduction 
of the new methods of diagnosis, of distinguishing the proper cases and 
their stage, were circumstances which one and all tended to render some- 
what indiscriminate the application of mercury. Here, as in all other in- 
stances of indiscriminate practice, the evil results must have far exceeded 
the beneficial. Under such circumstances it cannot be matter for wonder 
that careful practitioners should have opposed the practice, or that teach- 
ers should have laid it down to students as an axiom in practical medi- 
cine — that the employment of mercury in scrofulous diseases, but espe- 
cially in phthisis, was fraught with danger, and could be productive of 
no good. 

11 The injurious effects now alluded to as ensuing from the employ- 
ment of mercury in phthisis, are less attributable to the existence of pul- 
monary disease than to that of general disordered action of the whole 
system, of which the former is the consequence, and a certain indication. 
Our best writers agree in the belief that the full action of mercury in the 
scrofulous cachexia is singularly injurious ; that the depression which the 
medicine thus given produces is more effectual than any other in increas- 
ing the cachectic state, and, should tubercle exist, in hurrying it through 
its various changes. It has, moreover, been asserted, and probably with 
some justice, that the mercurial fever once excited has a great tendency 



524 CLINICAL MEDICINE. 

to increase hectic, and even in cases where this last condition has never 
appeared, to pass gradually into and terminate in it. Hence will appear 
the justice of the view entertained by Dr. Stokes, when he terras the 
remedy a two-edged sword, and expresses his conviction that its exhibi- 
tion must not be lightly attempted. 

" In coming to a conclusion as to the employment of mercury in any 
particular case, we have to decide on the propriety of employing means 
which are calculated to remove local disease, but do so at the expense of, 
and with some detriment to, the general constitution. In a word, our 
conclusion hinges on this, whether the local or the general disease be at 
this time the most important. Dr. Stokes writes as follows :* — ' As to 
the general employment of mercury in incipient phthisis, I am any thing 
but sanguine, yet that by its assistance in removing irritation from the 
mucous membrane and parenchyma we may occasionally arrest the 
development and progress of tubercle, seems more than probable, for 
there can be little doubt that in the scrofulous habit there is more danger 
from the persistence of irritation of the lung, than from the action of mer- 
cury on the system.' 

" The existence, then, of such irritation or inflammation, whether mem- 
branous, parenchymatous, or, as is most frequently the case, the two 
combined, is that which calls for immediate attention to the lung, even 
at a temporary disregard to the constitution. Dr. Corrigan says,f that 
the use of mercury is in removing that degree of low local inflammation, 
which, allowed to remain unchecked or improperly treated, would termi- 
nate in tubercular deposition and consequent phthisis. And Dr. Graves, J 
after mentioning those cases of consumption which arise gradually and 
insidiously, whose commencement it is impossible accurately to determine, 
goes on to say, ' the reason of this is because the tubercular affection of 
the lung is in such patients only of secondary importance, the disease 
which produced it having affected the whole system before the lung was con- 
taminated. This happens in some, but in others an opposite train of 
phenomena is observed, and scrofulous inflammation commences in the 
lung before any general contamination of the system has taken place. It 
is in such cases, and such only, that mercury ought to be tried, and it 
will avail nothing except where the commencement of the scrofulous 
inflammation of the lung has arisen suddenly, and in consequence of the 
operation of some obvious cause, as catching cold, or the occurrence of 
haemoptysis.' 

u It may then, in general terms, be stated, that the absence of pre- 
existing tubercular deposit from every organ of the body is the circum- 
stance justifying our neglect of the contra-indication which scrofulous 
cachexia presents to the employment of mercury. The word ' pre-existing' 
has been here introduced, because it seems likely from the physical signs 
that, in some cases terminating favourably, tubercular matter has been 
present in the lung before the mercurial treatment was commenced. In 
them, however, such deposit was trifling in amount, and secondary to, and 
dependent upon, the bronchial or parenchymatous inflammation, for the 
cure of which mercury had been employed. 

u An interesting and most important object of inquiry is, how far such 

* Op. cilat., p. 450. 

f London Medical Gazette, 2d Series, vol. ir., p. 74. 

$ Loc. citat. 



MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 525 

tuberculization may proceed, and the case nevertheless be amenable to 
mercury. Facts are wanting to decide this point. In one of Dr. Stokes's 
favourable cases, ' the antero-superior portion of the left side sounded 
comparatively dull.' In another, ' the right clavicle and scapular ridge 
sounded slightly, but decidedly dull.' In one of my cases (No. 4), there 
was slight dulness of the left scapular ridge ;* in another (No. 6), the 
same phenomenon, in an exceedingly slight degree, was perceptible upon 
percussing the left scapular ridge, the clavicle, and the two superior ribs. 
I must, nevertheless, in the face of these cases, express my conviction, 
that the presence of dulness diminishes greatly our chance of success ; 
and did the previous history and general symptoms leave me in much 
doubt as to the propriety of employing mercury in any particular case, the 
existence of a very moderate amount of dulness would induce me at once 
to omit its use. I agree, indeed, with Dr. Hughes in thinking, ' that 
appreciable dulness on percussion is very far from being an early physical 
sign of phthisis, and that when it is clearly distinguishable below one or 
both clavicles, or in the acromial regions, the complaint has generally 
advanced too far to be effectively treated.' It must, notwithstanding, be 
borne in mind, that dulness on percussion may even in cases of undoubted 
phthisis arise from other causes than the deposition of tubercle, and may 
either spontaneously, or from the effects of treatment, be considerably 
diminished, and even altogether removed from certain portions of the 
lung. The cause of dulness in such cases is either inflammation or con- 
gestion, and it is to intercurrent attacks of this nature, and their subsequent 
removal, that we are to attribute the alteration of the phenomena above 
mentioned. Many writers are of opinion, that the dulness occurring very 
early in consumptive cases is more owing to congestion or inflammation 
of the lung, than to the presence of tubercle. That such is the correct 
explanation of the cases above referred to, where dulness has been reco- 
vered from, seems more than probable. Every one at least must admit, 
that such an explanation is more consonant w r ith our knowledge of the 
habitudes of tubercle, and the effects of medicine, than that which would 
attribute it to the absorption of tubercle itself. Admitting the occasional 
absorption of tubercular matter to be a well-established fact, it yet remains 
to be proved, that such a process is favoured by the action of mercury 
upon the system. Without, however, denying that such may be the case, 
and allowing that analogy is in favour of the supposition, it must be con- 
fessed, that the present state of our science by no means warrants us in 
receiving this effect of mercury as more than probable. 

"The period, however, which may elapse between the commencement 
of the indisposition and the deposit of such a quantity of tubercle as to pro- 
duce dulness, varies much in different cases. It may be stated, perhaps, 
as ranging between three weeks and three months. I have known the 
lung so far solidified within the former period, as to put the use of mercury 
quite out of question. The attack supervened in this instance upon mea- 
sles. In the course of three weeks the superior portions of each lung gave 
a perfectly dead sound upon percussion, and there was an entire absence 
of respiratory murmur in the same parts. The patient, aged 18, died 
within nine weeks from the commencement of his illness, and upon exa- 
mination, cavities were found in the apex of each lung; the surrounding 
parts being completely solidified. That the condition above described 
may continue for eleven weeks, and so small an amount of tubercle be de- 



526 CLINICAL MEDICINE. 

posited, as but slightly to impair the sonoriety of the lung, is proved by 
the case of Thomas Smith (No. 6), below detailed. My experience has 
not been sufficiently extensive to enable me to say whether or not it may 
last longer without giving rise to marked dulness. Two cases I have wit- 
nessed, the histories of which were so perfect, as to leave little or no doubt 
as to their nature, where a period little exceeding three months sufficed 
to induce well-marked dulness, and render the use of mercury inadmissi- 
ble. One of these cases came under my observation fourteen, the other 
fifteen weeks from the commencement of the illness. That the usual course 
and tendency of scrofulous bronchitis or pneumonia are not represented by 
these extremes is sufficiently probable. The rapidity of progress observed 
in one instance, and its protracted duration in another, must be looked 
upon as exceptions to a general rule. The average duration of this pri- 
mary stage will, I think, be found in a period about intermediate between 
the extremes above mentioned. Although speaking doubtfully on this 
point, I am at least certain that the rapidity of progress within a given 
period increases in a direct ratio with the duration of the disease. Thus, 
for instance, if we compare two patients, one of whom has been suffering 
five weeks, the other eight, and whose symptoms at the time of our com- 
parison are as nearly alike as possible, we shall find that after a given time, 
say a week or a fortnight, a much greater progress has been made in the 
latter than the former. It is thus only we can explain a circumstance con- 
stantly noticed by such patients, that their symptoms were at the commence- 
ment comparatively stationary , or at most made but slight progress ; that sub- 
sequently they became more and more rapid in their course, and latterly each 
day has sufficed to induce a well-marked increase in every symptom. We 
deduce from this fact an important practical precept — to lose no time in put- 
ting the patient under the specific influence of mercury, and this more espe- 
cially when the case has been at all protracted. The delay of a few days 
early in its course may be without ill effects, and will probably, in many in- 
stances, be advantageous, by giving time for the employment of important 
preparatory or auxiliary means; but where such symptoms have persisted 
for a much longer period, any considerable delay is likely to be followed 
by serious consequences; for the disease may thus advance to such a de- 
gree, as to place it out of reach of medical assistance. 

u Admitting the injurious influence of mercury upon the general consti- 
tution, yet having determined upon its employment for the removal of 
local disease, an object of no slight importance is to administer the medi- 
cine in such a manner as to obtain to the utmost the beneficial effects it is 
capable of producing upon the lung, whilst we avoid, as far as possible, 
the damage it may do to the constitution. The more immediate of the 
injurious consequences of mercury are fever, great nervous irritability or 
disorder of the alimentary canal, whilst the more remote, though not less 
important, morbid states are, in a great measure, dependent upon, and 
originate in, one or other of the three conditions just enumerated. To ob- 
viate, then, or diminish these as far as practicable, is our only chance for 
good. Much may be done in the way of prevention, by the employment 
of preparatory treatment — a point too much neglected in the present day, 
but to which the attention of the profession has recently been directed in 
a forcible manner by Dr. Colles. Fever, in the proper sense of the word, 
is a rare result of mercury in the scrofulous diathesis. It does, however, 
sometimes occur, and chiefly in those individuals who present more or fewer 



MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 527 

of the indications of plethora — who have a firm, unyielding pulse, and other 
indications of the phlogistic habit. These, it must be confessed, are rare 
concomitants of the scrofulous diathesis: they frequently occur, however, 
in the form of pyrexia, as symptomatic of local inflammatory action ; but 
whether primary or secondary, their existence predisposes strongly to the 
occurrence of mercurial fever. In a primary or idiopathic state we rely 
chiefly on aperient medicines, saline diaphoretics, quiet, and low diet. 
These means, pursued for a few days, are usually sufficient to reduce all 
inflammatory disposition, and to pave the way for the mercurial course. 
But when originating in local inflammation, other measures, as blood-let- 
ting, either local or general, may be required in addition. This feverish 
condition, despite all preparation, will commonly occur in a greater or less 
degree immediately preceding the establishment of mercurial action on the 
gums. It is evidenced by the usual phenomena of pyrexia, and by an 
aggravation of the local symptoms, for the cure of which mercury has been 
employed. The application of a small number of leeches, and the admi- 
nistration of saline diaphoretics, will suffice to control these symptoms, 
which, however, either spontaneously diminish or subside on the establish- 
ment of ptyalism. As the more frequent consequence of mercury, we no- 
tice nervous irritability, which, in the scrofulous habit, it is next to impos- 
sible wholly to avoid. A clear state of the intestinal canal, and a healthy 
aspect of the evacuations, are the conditions best calculated to ward orf 
such a state. If not already existing, they should, therefore, be obtained 
by medicine ere the use of mercury is commenced. Notwithstanding this 
preparatory treatment, it will usually be advisable to combine either seda- 
tives or narcotics with the mercurial. A light bitter infusion may, in some 
cases, be advantageously substituted for or combined with the sedative. 
This practice is called for more particularly where, in addition to great 
debility, there is a clean, moist tongue, healthy condition of the excreta, 
and copious perspirations. Sarsaparilla often acts kindly as a soother of 
the irritable state of the nervous system, producing a greater tranquillity 
during the day, and more comfortable nights, than will any selection or 
combination of narcotics. To this end the infusion of Dr. O'Beirne, pre- 
pared with lime-water, seems peculiarly adapted. Disordered condition 
of the alimentary canal is a frequent accompaniment and cause of the ner- 
vous irritation above mentioned. It may, however, occur, per $e, but 
whether alone, or in combination, its removal is a point of the first impor- 
tance in our treatment. Where there is reason to apprehend the superven- 
tion of this condition, the exhibition of mercury should be preceded by a 
mild, yet efficient laxative. Rhubarb with soda and a few drops of tinc- 
ture of hyoscyamus in an aromatic water, will here be found highly bene- 
ficial. Any irritation or uneasiness remaining after the free evacuation of 
the bowels, will commonly subside in a short time under the use of alka- 
lies with hyoscyamus and mucilage. Mercury, in its mildest form, should 
then be entered on, and its action may be guarded by combination with 
an alkali, as chalk, or with this and Dover's powder. 

"During the mercurial course attention to diet and regimen must be 
rigidly enforced. The patient should be placed on the farinacea, or milk; 
animal food, fruit, vegetables, fermented, vinous, and spirituous liquors, 
being altogether proscribed. He should inhabit a large, airy, well- venti- 
lated apartment, constantly maintained at one temperature, and, in addi- 
tion, should wear next the skin a fine flannel garment, enveloping the 



528 CLINICAL MEDICINE. 

whole body from neck to foot. With the preparatory and concomitant 
measures now recommended, mercury will generally be well borne, and 
its use, when once commenced, must be regularly continued until the 
gums become affected. From an irregular and indecisive administration 
of this medicine, ill effects will almost invariably result. Should it, there- 
fore, manifestly disagree, its exhibition must be immediately and finally 
desisted from. In other instances, where but slight phenomena of dis- 
order occur, it becomes a question, to be decided only by the circum- 
stances of the individual case, whether, despite of these, to continue its 
employment or withdraw the medicine and attempt to remove the cause 
upon which its injurious effects appear to have depended. In the latter 
instance we may, perhaps, be justified in once more resorting to its use ; 
but if it again disappears, the medicine must be at once withdrawn, never 
more to be employed. 

" I have usually combined in one formula, with the mercurial, ipeca- 
cuanha and a sedative ; the frequent irritative and distressing cough com- 
monly attending this disease, proving, as it does, a constantsource of dis- 
quietude through the day, and of restless nights, with the results of broken 
rest, are indications sufficiently clear (independent of those derived from 
the general habit) for the administration of sedatives. Hyoscyamus, or 
conium, are those w T hich I principally employ ; but where these fail of 
producing the desired effect, recourse may be had to hydrocyanic acid, 
belladonna, the salts of morphia, &c. Ipecacuanha acts beneficially in 
freeing the expectoration, and I am inclined to think, determines the 
action of mercury more particularly to the bronchial mucous membrane. 

" However beneficially these measures may operate, it must not be for- 
gotten that the employment of mercury is but preparatory to other and 
more strictly curative treatment. After the removal or suspension of local 
disease by mercury, an equally or even more difficult task remains of cor^ 
recting the cachectic condition upon which has mainly depended the local 
lesion. The patient, no less than the practitioner, should remember that 
from extreme and immediate danger he has only been snatched by severe 
and almost equally dangerous means ; that the same liability to local dis- 
ease exists as before, ready again to start into existence upon the applica- 
tion of the slightest exciting cause. One great object in administering 
mercury is to gain time for the employment of measures to restore the 
general health, by removing a local action which, allowed to continue, 
would give rise to such disorganization as quickly to place the patient out 
of the pale of cure, and long ere means calculated to work a salutary influ- 
ence on the constitution could take effect. Unless this truth can be fully 
admitted, and the practice to which it leads rigidly enforced, mer- 
cury should upon no account be administered. It does not fall within 
the purport of this paper to discuss the treatment best adapted to the 
cure of scrofulous cachexia. This has, indeed, been so fully done by 
Sir James Clark, in his thirteenth chapter, as to leave nothing to be 
desired.* 

" With these prefatory remarks, I proceed to detail the nine cases 

9 u Pitcarne, as quoted by Allen, Synop. Univ. Med., ed, v.. p. 159, Lond., pursued a prac- 
tice not unlike that herein recommended : — '■ Quamdiu tabes est in primo gradu et probabile 
est sanguinem non esse extravasatum ulcusve nondum factum debet ante usam decoct: ex 
lignis et dum purgantibus ulimur adhibcri mercurius dulcisnon qnicem cum purgantibus simul 
eodem die sed sine purgantibus post aliquot dies.' 



PERIOSTITIS. 529 

which I have subjected to the mercurial mode of treatment. Five of them 
have recovered ; one was temporarily relieved, but died subsequently of 
phthisis ; three experienced little or no benefit from the treatment adopted. 
These, with the cases of the Dublin physicians, are twenty-one in num- 
ber, of which eleven were cured, three considerably benefited, six expe- 
rienced no relief, and in one, the medicine disagreeing, could not obtain 
a fair trial." 

I regret exceedingly that space will not admit of the insertion of the 
notes of Dr. Munk's nine cases of this disease treated by mercury. 



LECTURE XL. 

PERIOSTITIS. 

Gentlemen, — Before I enter on the subject of our intended lecture, I have 
to remark, that there are some cases in the hospital possessing considera- 
ble interest. Those to which I would particularly direct your attention, 
are three cases of pneumonia, in which the stethoscopic phenomena are 
palpably and distinctly marked. I am anxious that junior students should 
examine these patients, and with them commence the investigation of 
chest diseases, because the indications in the cases alluded to are so ex- 
tremely plain and obvious. Much of the discouragement which students 
experience in endeavouring to become stethoscopists, arises from the 
obscure and doubtful nature of the cases which are too often presented to 
them in the very commencement of this study. 

I would recommend beginners to examine, at first, the peculiarities of 
healthy respiration in boys, and then in adults, and never to apply the 
stethoscope to a diseased chest until they have been first informed, by 
some competent person, of the presence of well-marked phenomena. In 
one of the cases above stairs, the rale crepitant is exceedingly distinct ; 
and having once heard it, you will always be able to recognise it with 
facility. There is also a man affected with phthisis, in whom the gargou- 
illement is so audible, that the merest beginner, on applying the stetho- 
scope under the clavicle, would say he heard the gurgling of air entering 
a cavity containing fluid. I point your attention particularly to this case, 
because its self-evident nature renders it highly valuable. We have also 
a well-marked case of haemoptysis, or spitting of blood, a term which I 
prefer to that of pulmonary apoplexy. This man had laboured under this 
affection for some time, and two days since spat, during the course of the 
night, about three pints of blood. There are many cases of cerebral dis- 
ease, vertigo, epilepsy, and paralysis arising from apoplexy, or following 
painter's colic ; so that those willing to instruct themselves will find the 
field for observation sufficiently ample. 

I shall now proceed to make some remarks on the general pathology 
and treatment of periostitis. I regret to state that the articles on this sub- 
ject in Cooper's Surgical Dictionary and other works are deficient in a 
practical point of view. It is a disease which has been known as long as 
syphilis ; but its true pathological nature was not pointed out until Sir 
Philip Crampton described it in the first volume of the Dublin Hospital 
35 



530 CLINICAL MEDICINE. 

Reports. We have frequently heard tenderness of the skin, with increase 
of size, termed swelling, or diseased growth of the bone ; but you will 
find that, in most of these cases, the swelling and other symptoms are 
owing to the peculiar state of the periosteum alone. Periostitis is a dis- 
ease of considerable importance, because its symptoms are produced by 
scrofula and other cachectic states of the constitution, as well as by the 
abuse of mercury and other remedies. You will have occasion to observe 
instances of this disease superinduced by cold, or by giving mercury un- 
der unfavourable circumstances, and in the latter case frequently con- 
founded with syphilis. This is an important fact, and you should hold it 
in memory. Another great mistake is, confounding it with neuralgia, or 
where it attacks the head, with hemicrania, because one side of the head 
only may be affected, and the pain may be increased at a stated hour, 
generally towards night. I have seen the carbonate of iron given in large 
doses by a medical gentleman of considerable eminence, to cure a pain in 
the side of the head, which arose from inflammation of the periosteum. 
Another instance of a similar kind has lately come under my observation 
in private practice, and once I committed the same mistake myself. 

Before I enter into the further consideration of this subject, I must state 
to you that an opinion was formerly entertained, that membrane or peri- 
osteum was the repairer of bone, where its regeneration was necessary. 
But in this process, the vessels of the bone itself are as much concerned, 
and membrane contributes nothing to the formation of bone, except so far 
as its vessels are engaged. The formation of callus in fractures, the devel- 
opment of healthy bone in necrosis, the organization of node and exostosis, 
depend not on any membrane, but on the vascular part of the periosteum, 
and on the vessels of the bone itself. It is true, however, that where 
other vascular channels are cut off, the periosteum will, to a certain 
degree, supply their place, thus becoming the sole means of establishing 
vascular communication. It is to Scarpa we owe our information on 
the true nature of the reparation of bone. You will find, on this sub- 
ject, a great number of experiments detailed in Cooper's Surgical Dic- 
tionary. 

With respect to the periosteum, it is, like other parts of the system, lia- 
ble to inflammation ; but you are not to suppose that its liability is greater 
than that of other tissues. This would contradict the arrangements of 
nature ; for it is with this membrane she has clothed many parts of the 
body which lie close to the surface, as the shins, head, ribs, elbow, and 
other joints, which, besides the periosteum, have, for the most part, only 
a thin covering of integuments. You all know how frequently the peri- 
osteum is exposed to injury in the foot-ball matches at schools, and at our 
Irish fairs, and with how much impunity. I may observe here, that the 
term I shall employ in speaking of the affections of this membrane, peri- 
ostitis, is a name introduced by Sir Philip Crampton. Now, according 
to the view which I have taken of the formation of bone, it will appear 
that the subjacent bone is often as much diseased as the periosteum, and, 
indeed, sometimes the disease commences in the bone, and afterwards 
extends to the periosteum. With this exception, the definition given by 
Sir Philip Crampton is good. I beg leave to mention, en passant, that 
Mr. Howship's papers on the Formation and Diseases of Bone are deserv- 
ing of your perusal. He has examined and given delineations of the 
various structures of diseased bone ; but I do not consider his account of 



PERIOSTITIS. 531 

the structure of bone to be sufficiently established to enable us to deduce 
important pathological facts. 

There are numerous interesting preparations, illustrative of this subject, 
in the Museum of the Dublin College of Surgeons ; and there is none who 
can do more towards improving our notions on the structure of bone than 
its late scientific curator, Dr. Houston. He has formed a classified cata- 
logue, in which a minute account is given of the pathological circum- 
stances of each case, and the attendant symptoms during life. I need not 
say this is a valuable acquisition to our stock of knowledge. In the course 
of our inquiry I shall communicate to you several useful hints on perios- 
titis, which I received from Dr. Houston. 

You will observe, gentlemen, that, in inflammation of the periosteum, 
the peculiar texture of this membrane modifies the symptoms of the dis- 
ease. The periosteum is fibrous, and, though not thick, is remarkably 
strong and unyielding, lacerated with difficulty, and does not accommodate 
itself, except to that which it was intended by nature to cover ; hence, if 
a part increases in size, the periosteum over it is stretched and tightened, 
and this is one of the principal causes of the severe pain usually felt. 
You are aware of the swelling which attends the common forms of inflam- 
mation of cellular substance, where the parts can extend themselves on 
every side, must be differently circumstanced from that which arises from 
abscess, under fascia, or lying close to a bone, and that there must be a 
corresponding difference in the pain. You will find, in various surgical 
works, that, in periostitis, the pain is sometimes great where very slight 
changes have taken place, and that little pain is felt in some cases where 
there is considerable alteration of structure. 

It is a remarkable fact, that, in many instances of periostitis, exactly 
corresponding parts of the bones of different extremities, on different sides 
of the mesial line, will be found simultaneously or successively attacked. 
Thus, if a certain spot on the bones of one fore-arm, or one acromion, or 
any other part of the scapula, be attacked by inflammation, similar ap- 
pearances will manifest themselves in the other, either at the same time, 
or in a few days after. If it seizes on one clavicle, you soon observe it 
in the other. You will have occasion to treat this disease in perhaps 
most of the human bones, but particularly in the head, tibia, femur, ster- 
num, and scapula. In the sternum it sometimes leads to a carious de- 
struction, forming a large hole in the bone, as happened in a young man, 
formerly in this hospital ; in his case, each stroke of the heart caused 
matter, mixed with air, to bubble out, presenting a very curious and 
frightful appearance. Periostitis, occurring in the neighbourhood of joints, 
often spreads to the joint itself, giving rise to periostitic arthritis. Thus, 
from the tibia, it frequently spreads to the knee, or ankle, and from the 
humerus, or scapula, to the shoulder-joint. The sternal articulation of 
the clavicle is a favourite seat of periostitis. In the ribs, it much more 
frequently attacks them in their anterior portion, not far from the sternum, 
or from their cartilages, and occasionally gives rise to costal caries, for 
which Cittadini has recommended a particular operation. I would re- 
commend you to hold in memory, that when the disease affects the thigh- 
bone, it is almost invariably about the junction of the middle and lower 
thirds, and generally on its anterior or inner surface ; this is a practical 
observation which I have not seen noticed in books.* There is also, in 

* Mr. Colles has, since (his lecture was delivered, alluded to the occurrence of nodes in 



532 CLINICAL MEDICINE. 

this form of periostitis, one peculiarity that, besides the very great severity 
of the pain which attends it, we find that it yields with the greatest pos- 
sible difficulty to medicine, and that the means of curing it are a deside- 
ratum we have still to discover. The next specie's, most remarkable for 
its painful symptoms, and one which deserves to be explained more fully, 
is periostitis of the head. There are three subdivisions of this species. 
The first kind is very easily recognised, for you will find the affected spots 
sore, slightly swelled, and hardened, with marked tenderness on pressure, 
and the headache, which accompanies them, radiating from these spots as 
from so many centres. In the second form you will find the pain obscure 
and not confined to a certain spot, but the swelling and thickening of the 
scalp are evident, and give certain indications of the nature of the disease. 
You may also observe cases where the inflammation is diffused over one 
side of the cranium, and not fixed to a small distinct spot, and these are 
attended with severe pain. With respect to these varieties, you will not 
find much difficulty in ascertaining their nature : but there is another kind 
in which the diagnosis is much more obscure. A patient, for instance, 
complains of severe headache, at first attended with intermissions, gene- 
rally increased towards night, and accompanied with a sense of weight in 
the head ; his eyes look watery and heavy, and lose their usual animation, 
and his spirits are depressed ? Ask him in what part of his head he feels the 
pain, and he cannot tell you exactly. Sometimes he refers it to the fore- 
head, sometimes to the side of his head. There is no point of the scalp in 
which you can detect any soreness or swelling. Matters go on in this way 
for some time, he begins to lose his rest, the intermissions become shorter 
and not so perfect, and the pain increases. During the day it is tolerable, 
but, towards evening, it is excruciating, and does not allow him to enjoy 
one hour's rest in the twenty-four. The largest doses of opium, and other 
strong narcotics, are useless. Rest in bed, stupes, cold lotions, narcotic 
liniments, even bleeding and leeches, give but very small relief. After 
exerting all your ingenuity, you still have the mortification of finding that 
there is something wrong going on, which eludes your skill. On your 
first visit, from the appearance of the patient and the detail of his symp- 
toms, you are led to suspect that the brain is the part diseased. You 
employ your antiphlogistic remedies, but find no improvement, and begin 
to doubt the correctness of the diagnosis. Moreover, in cases of this kind 
(where you will find a tenderness in the integuments on close examina- 
tion, and pain limited to one side of the head), there is, occasionally, a 
partial ptosis of one eyelid, which creates alarm, and leads you to imagine 
that it is the brain itself which is affected. Ptosis, or falling down of the 
upper eyelid, is a very frequent symptom of cerebral disease ; and, con- 
sequently, in determinations to the head, in fever, and other complaints, 
it is a bad sign when one eye, in consequence of some degree of ptosis, 
appears smaller than the other. There is certainly some degree of para- 
lysis in this case, but it is only secondary, and not depending on the 
brain, but on the inflammation, affecting the nerves themselves. I men- 
tion this because it is not generally known or described, and because it is 
liable to excite alarm. Now, why is this disease not easily recognised, 

this situation, in his work on the Venereal Disease. He points out the many symptoms gene- 
rally supposed to characterize morbus coxae, which attend this affection, and particularizes the 
diagnostic features of the two diseases. — Vide Colles on Venereal. 



PERIOSTITIS. 533 

or why is the bone So often devoid of tenderness to the touch ? It is 
because the internal surface of the bone is the part first engaged, and the 
disease cannot become evident until after some time. After your usual 
treatment has been continued for a week or ten days with little improve- 
ment, a certain spot on the head will be found tender on pressure, and it 
is only then that the true nature of the case will appear. For this disease 
there is no cure but mercury iodine. However useful depletion may be 
to prepare the system, nothing but the seremedies in large doses will re- 
lieve the disease. Give a scruple, or half a drachm of calomel, in the 
course of the day, and bring the system thoroughly under its influence. 
You will do well to combine different proportions of this remedy, as there 
are some constitutions which are more quickly affected by one preparation 
than by another, and then combination is always valuable. It is very 
remarkable, that though you have made the month sore, relief is not im- 
mediately obtained ; you must go on and affect the system, very decidedly, 
and when you have accomplished this, the pain and other symptoms will 
disappear. Of this we have an instance in the chronic ward. A perios- 
titic patient had his mouth sensibly affected for several days, but with 
very little relief of pain. What did we do ? We doubled the dose of 
calomel, and in a few days the pains had altogether disappeared. You 
may have perceived analogous instances in cases of iritis, where the dis- 
ease begins to diminish on the mouth being made sore, and even may 
appear to have entirely subsided. Encouraged by this, the practitioner 
decreases the dose of mercury ; the mouth continues sore, but in a few 
days, although the small doses of calomel are continued, and although the 
mouth is still affected, the characteristic symptoms of iritis again recur, 
and go on increasing, if you continue to trust to the diminished doses of 
calomel. Under such circumstances, a beginner might be discouraged, 
and lose confidence in mercury, because the iritis had returned while the 
mouth was still sore, and before the remedy was discontinued. What is 
to be done ? Instantly resume the large doses of calomel, with a more 
decided mercurial action, and the iritis disappears.* In the mercurial 
treatment of periostitis, arthritis, peritonitis, and pleurisy, a similar me- 
thod of managing this remedy is occasionally required, and it is of vital 
importance that you should know this. 

With respect to that species of periostitis which affects the femur you 
must recollect, that this bone lies so deep, that it is sometimes not very 
easy to detect the periostitic swelling. Generally it is the part of the 
bone before mentioned which is attacked, and in the cases I have seen, the 
inflammation was on the inner side of the bone. From its situation, this 
species is very apt to be mistaken for various diseases, particularly neu- 
ralgia, sciatica, abscess in the shaft of the bone, morbus coxae, &c. After 
some time, a certain degree of tumefaction may be distinctly felt, but not 
until the patient has suffered excruciating agony and distressing want of 
sleep ; indeed in one case the poor sufferer scarcely slept at all for twenty 
nights in succession. One of these cases was relieved by corrosive sub- 
limate, but two others were not in the least improved by mercury pushed 
to the utmost. Narcotics totally failed, but a seton over the affected part 
seemed to do some good. But, to return to periostitis affecting the 
cranium ; it occasionally assumes the chronic form, attacking both sur- 

* These are the kind of cases that have since been found to yield rapidly to the influence of 
spirit of turpentine, as first recommended by Mr. Hugh Carmichael. 



534 CLINICAL MEDICINE. 

faces of the bone, in a slow insidious manner. The following instructive 
example of this affection fell lately under my observation : — 

A young man, of good constitution, previously healthy, became subject 
to epilepsy, very frequent and violent. Some time previously he had 
complained of headache, chiefly referred to the left side of his forehead. 
The convulsions on the right side were stronger than on the left. He 
continued in this state for many months, and became incapable of pur- 
suing his usual occupation. The convulsions became more frequent, recur- 
ring at different times in the day ; and some of his medical friends thought 
they observed a prominence in the frontal part of the skull, and were 
anxious to have him trephined in that spot. On looking at him in front, 
you could not at once perceive any unnatural elevation in the forehead ; 
but, by examining it from above downwards, according to the norma 
verticalis of Blumenbach, there was a perceptible swelling, as if the whole 
bone had been pushed forward in that situation. After seven months' 
illness, he was seen by Dr. Colles, Sir Philip Crampton, and myself. 
We objected to hig friends' proposal to trephine, because we could not 
be certain that there was any projecting growth of bone pressing on the 
brain in this place, and because it had a certain degree of tenderness on 
pressure. We were afraid, also, that there was an intimate union between 
the internal periosteum and the dura mater, as well as between the latter 
and the surface of the brain ; consequently there was danger that the 
operation might induce inflammation in all these parts. Considering it 
to be a case of internal periostitis, in which the inner table of the bone 
and corresponding part of the dura mater were affected, we agreed to try 
the effect of mercury. We employed frictions for this purpose, as the 
internal exhibition of mercury produced sickness and vomiting ; and at 
the end of eight or ten days, when the mouth became affected, we had 
another consultation. We were told there was no improvement ; the fits 
still continued ; his friends exclaimed that mercury was useless, and called 
for the application of the trephine : we were almost in despair. On closer 
inquiry, however, we found that though the fits had displayed the same 
violence, there was some slight diminution in their frequency, and on this 
slender hope we urged the continuance of the same remedy. As soon as 
his system was completely affected, the disease began to decline percepti- 
bly, and he became free from pain, and the convulsions ceased. 

When the vertebra? become the seat of periostitis from syphilis, scrofula, 
or abuse of mercury, it will be generally found in the bodies of the verte- 
brae. When brought on by syphilis alone, I believe, it seldom attacks 
the bodies, such cases arising chiefly from the abuse of mercury or scrofula. 
In persons of broken constitution from combined venereal and improper 
mercurialization, it is not an uncommon occurrence to find the neck pre- 
senting the symptoms of subacute crick, or collum obstipatum, which, if 
treated in the common mode, the disease becomes confirmed ; and of this 
I have seen an instance in a gentleman, whose neck became permanently 
stiff for want of skill in his medical attendants. It will be obvious that 
inflammation of this kind, affecting the vertebras, may be readily com- 
municated to their ligaments and the adjoining tendons, and in this way 
produce the deformity. I have treated some such cases, and would turn 
your attention to it, because you will not find it mentioned in books. 
You will be able to know it by careful examination, by pressure, and find 
that its cause was disease of the periosteum of one, two, or three of the 



PERIOSTITIS. 535 

vertebrae ; and you will employ, in treating it, leeches, repeated blistering, 
and compound decoction of sarsaparilla, with hydriodate of potash. If 
this does not do, mercury, and, except the disease has continued too long, 
you will cure it. Other vertebrae, as those of the back and loins, may 
become the seat of periostitis, and it may be mistaken in those cases for 
Pott's disease, or for Teale's spinal neuralgia, from which it is sometimes 
difficult to distinguish it. Periostitis sometimes attacks the sacrum and 
os coccygis, and is then peculiarly painful, as is now exemplified in the 
male ward. In females, 1 have been twice consulted within the last year 
for a pain in these same parts, which was at times excruciating, and 
always considerable ; it was increased to an intolerable degree by sitting 
down, and hence they were obliged to avoid society. It appeared to be 
a variety of hysterical neuralgia, and yielded to nervous medicines com- 
bined with tonics, together with the local application of stupes, narcotic 
liniments, &c, &c. I know not whether authors have mentioned this 
peculiar neuralgia. 

When periostitis attacks the sternum, it is very liable to be mistaken 
for disease of the chest. I remember a young gentleman, some time ago, 
who had a severe pain in his chest, which gave his father such alarm, 
lest it might be consumption, that he brought him with him to London 
for the benefit of change of air and to have medical advice. On his way 
thither he caught a cold, and in this condition waited on a medical gen- 
tleman, who prescribed medicines for him adapted to the cure of pulmo- 
nary disease. On his return to Dublin (his pain still continuing) I was 
called in to treat him for a complaint in the chest. On placing the steth- 
oscope over the spot where he complained of pain, he winced, and, after 
a minute examination, I discovered that the disease was entirely con- 
fined to the periosteum. It is possible, however, that in such cases, the 
disease may ultimately reach the chest, for the sternum is a very porous 
and spongy bone, and a complete perforation of its substance may be the 
result of periostitis long continued. Another way in which it may be 
confounded with rheumatism of the intercostal muscles, or pleurisy, is 
where periostitis attacks the ribs. This is a very common source of pain, 
tenderness, and stitch of the side. 

There is a form of periostitis which extends from the bones of the foot 
to the plantar aponeurosis ; it is found chiefly in labouring men ;• and the 
predisposition to it seems to arise from the use of the spade in digging. 
I do not know that this form has been mentioned by any author I am ac- 
quainted with. The following symptoms are generally present. The pa- 
tient complains of excessive pain in the sole of the foot, extending into one 
or both malleoli whenever he attempts to lay the plantar surface flat on the 
ground, and in order to save himself, he walks either on the heel or outer 
edge of the affected foot, the toes of which are strongly contracted, so as 
to relieve the tense condition of the plantar fascia. The pain is much in- 
creased when pressure is made in the centre of the sole or on one of the 
malleoli, these latter processes being generally enlarged, and accompanied 
with swelling of the adjacent parts. Besides the pain produced by pres- 
sure on the plantar surface, the patient generally suffers from lancinating 
pain through the ankle-joint. This disease is one of frequent occurrence, and 
many cases of it are admitted every winter into the Meath Hospital, where 
it is familiarly known by the name I have given to it, viz., " Plantar Rheu- 
matism." The most severely painful instance of all the varieties of peri- 



536 CLINICAL MEDICINE. 

ostitis is, perhaps, the paronychia periostei, or bone-whitlow, to which, 
as it belongs to surgery, and its treatment is well known, I shall merely 
allude. 

I shall now enter into the consideration of the special pathology of pe- 
riostitis. This disease may be divided into two kinds, the diffused and 
the circumscribed. With the former we have nothing to do, it is never 
found in the medical wards, and comes properly under the care of the sur- 
geon. It may, however, be well to mention its chief characteristics. By 
diffused periostitis I mean that form which occupies a large portion of the 
periosteum, which arises from cold, accident, and other similar causes, 
which has no connection with, or dependence on particular states of con- 
stitution, or specific diseases, and which frequently terminates in necrosis. 
The other species, which comes more immediately under the care of the 
physician, I have termed circumscribed, from its comparatively small ex- 
tent. Circumscribed periostitis may arise from cold, but, in the majority 
of instances, its origin may be traced to some specific cause, as mercury, 
syphilis, or scrofula. It is a much more frequent disease than the former, 
and presents several varieties. In the first place, it may exist without 
detachment of the periosteum from the subjacent bone. Here the perios- 
teum becomes inflamed and thickened, while the bone beneath assumes a 
greater degree of vascularity and consequent increase of size. By this 
process, which is always comparatively slow, the connection between these 
parts is increased, and the tendency of the augmented vascular action is 
to form depositions. Hence, the thickening of the periosteum is some- 
times very great, and, in process of time, forms a very considerable cir- 
cumscribed tumour, which to the touch feels so solid, that it is often mis- 
taken for bone. In this stage of the inflammation, pain and tenderness are 
complained of in the affected part, and we sometimes find the integuments 
swollen and discoloured. Matters, however, after some time, assume a 
more chronic form, and the intensity of the symptoms diminishes, there is 
little or no tendency to grow larger, and the pain and tenderness undergo 
a change for the better, though they do not cease altogether. It is at this 
period that the periosteum, previously thickened, becomes more dense in 
its structure, and in some cases seems to be almost converted into a fibro- 
cartilaginous tissue. When this change has been effected, it is doubtful 
whether the diseased mass is ever again absorbed, though it must be con- 
fessed, that swellings, whose history and physical characters strongly in- 
dicate their having undergone this change, occasionally disappear altoge- 
ther in the course of a few months. Many instances will occur in the prac- 
tice of medicine, where cartilage, or even bone are absorbed under other 
circumstances, evincing the value of proper treatment, or the efficacy of 
unaided nature. To recapitulate : inflammation of the periosteum, attended 
by deposition and thickening, without effusion of fluid, by increased vas- 
cularity of the subjacent bone, and adhesion between it and the perios- 
teum, after remaining for some time, will be found to decrease in the vio- 
lence of its symptoms, and to assume a fibrocartilaginous hardness, and 
in this state it may be absorbed or not. That it may be absorbed, we are 
led to expect from analogy; for we see frequent instances of the absorp- 
tion of cartilage and bone ; but it will be often found to continue for life, 
and in some instances, to be converted into a true body node. It is worth 
your while to consider how the latter process takes place. Ossification 
commences in the thickened periosteum, and bone is formed, constituting 



PERIOSTITIS. 537 

in general a circumscribed bony node which rises from the external sur- 
face of subjacent bone. In process of time the external lamina of the true 
bone becomes absorbed, and at the same time, a cancellated structure is 
developed in the node, which becomes continuous with the cancelli of the 
bone beneath, and thus there is formed on it a kind of bony arch. We 
are not able to ascertain at what period this takes place; but you will find 
instances of this formation in a state of progress in Mr. Howship's account 
of some specimens in Mr. Heaviside's museum, in which he discovered 
that the external surface of the old bone was not quite absorbed, and that 
no cancelli were as yet formed. A considerable disfigurement is frequently 
the consequence, where this affection attacks various parts of the same 
limb; and you may have observed a man in the chronic wards, in whom 
the shape of the tibia is lost from this cause. A recurrence of those attacks 
gives rise to several irregular and partial elevations on the bone, which 
blunt its edges, and fill up its natural concavities, so as to leave scarcely 
a vestige of its original symmetry, a circumstance which may be frequently 
observed in the deformed tibiae of prostitutes. You observe, gentlemen, 
in the first stage of this disease, the thickened periosteum presents a uni- 
form density, but in process of time a cancellated structure makes its ap- 
pearance in their deep-seated portion, while, as in the natural shafts of 
long bones, a layer of firm osseous structure constitutes their surface. It 
is obvious, therefore, that in the first stage there is a distinct line of demar- 
cation between the new and the original structure ; while, in the second 
stage, no such distinct boundary exists, the cancellated portion of both 
being perfectly identified. 

The next form of periostitis is that which is attended with detachment 
from the subjacent bone, of which there are several varieties. In the 
first kind, you find that, in a space varying from twenty-four hours to 
eight or ten days, an elevation appears on some part of a bone, with pain 
and tenderness on pressure, and forming a hard tumour, giving to the 
touch the feeling of a solid substance. This error may be detected by a 
more accurate examination, and there will be some elasticity discovered in 
the swelling. The cause of its seeming to be a solid tumour arises from 
the manner in which the periosteum is tensely stretched over the effused 
fluid. In the second stage of this variety, there is a gradual diminution 
of the pain and swelling ; the fluid, w 7 hich was effused under the perios- 
teum, is absorbed, and the subjacent bone and periosteum become again 
united. This process generally occupies some time ; but there are 
instances where its accomplishment is more speedy. Of this nature are 
the tumours which arise and disappear with such rapidity on the scalp and 
elsewhere, which yield quickly to leeches and blistering, and after exist- 
ing for some weeks, or perhaps even days, vanish, and leave no sensible 
trace behind. The pathological distinction of these tumours consists in 
this: that the surface of the subjacent bone does not die, and, conse- 
quently, the process of reparation is short ; for when the effused matter is 
absorbed, there is nothing to prevent the adhesion of the bone and peri- 
osteum. 

The variety just described is not attended necessarily with ulceration 
of the skin ; but there is another kind, in which effusion, as just described, 
takes place, accompanied by increased vascularity on the surface of the 
bone beneath. The matter effused at length escapes through an opening, 
made by ulceration in the integuments, and nature effects a cure by means 



538 CLINICAL MEDICINE. 

of granulations, arising from the vascular surface of the bone, which, 
uniting with granulations from the periosteum and integuments, repairs 
the breach of substance, and produces consolidation of the separated 
parts. 

In the next variety, matter is effused beneath the periosteum, and the 
bone of the affected portion becomes vascular at a little depth, while the 
surface is white and dead, consisting of a thin, worm-eaten, cribriform 
lamina, which, after some time, separates and opens for itself a passage 
through the integuments. This exfoliation is followed by a growth of 
granulations from the vascular bone beneath, and the process of healing 
is perfected in the manner before described. In some instances, the dead 
lamina is not thrown off at once, but undergoes a very curious process, 
being perforated, and as if worm-eaten, and thus allowing the granulations 
thrown out by the healthy bone to pass through its structure until the 
whole of the disorganised plate is removed. Such are the chief varieties 
of periostitis, exclusive of that species which is observed in scrofula, and 
which, from the disease simultaneously affecting the bones and perios- 
teum, can scarcely be called periostitis. In some vitiated and cachectic 
constitutions, the periosteum becomes affected, in consequence of ulcera- 
tion commencing in the skin from rupia, boils, or ecthyma ; this, how- 
ever, I shall not enter into at present. With respect to the derangement 
which takes place in the skin, it always bears proportion to the internal 
ulceration, and in the first species mentioned there is scarcely any. In 
the other kinds, it is of great use at the commencement to cut down to 
the bone through the integuments and periosteum, as recommended by 
Sir^P. Crampton ; for this practice, by lessening the inflammation, limits 
the quantity of bone which is about to die, and consequently the extent of 
integument likely to be removed by ulceration. 

When we come to consider periostitis, and investigate its causes, we 
find that it frequently'arises from specific poisons, as scrofula, mercury, 
or syphilis. You have many opportunities, in the surgical wards, of be- 
coming acquainted with the characteristic marks of that form which owes 
its existence to scrofula ; it is generally milder in its symptoms ; there is 
less pain and tenderness ; the swelling is less ; and it is most commonly 
observed in young persons, in whom we cannot suspect the operation of 
syphilitic or mercurial causes. I do not, however, mean to say, that you 
will not find the latter causes combined with scrofula, even in very young 
persons ; but such an occurrence is rare. But where this disease occurs 
at later periods of life, you are sometimes puzzled to decide whether it is 
a consequence of syphilis, or whether it is superinduced by mercury. 
When called to a case of this kind, inquire accurately into its history, 
and if you find that the person has taken mercury for the cure of primary 
or secondary symptoms, that it cured the disease, and the cure was de- 
cided ; that in a week, a fortnight, or a month after this the patient was 
exposed to cold ; that a great number of spots are simultaneously affected, 
and in corresponding parts of the limb, — you will be led to conclude that 
the disease is mercurial periostitis. About a week ago, a young gentle- 
man called on me with several periostitic swellings on his bones. I said 
to him, " You were taking mercury within the last six weeks." He said 
he was. " You then went out and got cold." He said he had ; and in 
this way I extracted from him the history of his complaint, and guessed 
it with such accuracy, that he stared at me as if I had a hundred heads. 



PERIOSTITIS. 539 

Such a case as this, gentlemen, arises from cold affecting the constitution, 
while under the influence of mercury. But there is still a more perplex- 
ing one; you may have mercurial periostitis mixed up with venereal 
symptoms. Ihis is no uncommon thing among persons advanced in life, 
who have had frequent attacks of venereal, and undergone repeated 
courses of mercury. You have the two diseases blended in a very com- 
plicated form, and then indeed are we placed between Scylla and Cha- 
rybdis, mercurial action producing a cachectic state of constitution, and 
venereal a diseased state of certain parts. Moreover, you are all aware 
every thing that impairs the constitution has a tendency to bring on scro- 
fula. Now, take a person who is suffering from syphilis ; deprive him, 
as you often must (from the confinement a mercurial course requires), of 
pure open air, keep him on low diet, and what is the consequence ? To 
the syphilis and mercurial cachexy, you have scrofula frequently super- 
added, and that hideous combination of disease which we sometimes meet 
with at the present day, but fortunately not so often as formerly. Some 
years ago, all such cases were mercurialized — often to death. In the 
wards of the Lock Hospital in this city, the progress of the patient towards 
cure was calculated in proportion to the number of pints he spat during 
the day. In the skulls of persons who lived during the last century, pre- 
served at Leyden, the destruction of the bony tissue is extraordinary : 
indeed, a phrenologist would be often puzzled by the havoc made by 
disease among the organs of our forefathers. An old writer, I think it is 
Herodotus or Zenophon, says, that the skulls of the Egyptians, lying on a 
field of battle, could be recognised by their hardness. Those of the last 
century, it seems, we can distinguish by their softness. This is no longer 
the case ; longevity, in the present century, is remarkably increased; and 
I think there are some countries which will be considerably raised in the 
scale of population from the improvements introduced in the treatment of 
venereal ; for this we are chiefly indebted to English surgeons and phy- 
sicians. Much credit is due to Sir Thomas Moriarty, Mr. Mathias, Mr. 
Carmichael, and other surgeons, who were the first in pointing out the 
baneful effects of excessive courses of mercury. Dr. Thomson, of Edin- 
burgh, has also done a great deal in promoting our knowledge on this 
point. It is but justice to mention, while speaking on this subject, the 
valuable and important services of our fellow townsman, Mr. Carmichael. 
When he first published his observations on the treatment of venereal 
disease, his opinions were looked upon as merely theoretical by most of the 
surgical profession here, and his practice industriously decried. I do not 
go so far as to admit all that Mr. Carmichael has advanced ; but it is 
from him we first received abundant proofs, that the majority of the cases 
of syphilis can be cured without mercury, and this is highly important. 
To the knowledge of this fact, to the more judicious employment of mer- 
cury, to the introduction of vaccination by Jenner, at the beginning of the 
last century, and to the general improvement, not only in diet, but also 
in medical and surgical treatment, we are to attribute the increased lon- 
gevity of the present period. Human life had almost doubled, and we 
began to hope that in 1900, it might be quadrupled. The mortality in 
London decreased in the proportion of 15 per cent., and the profits of 
Insurance Companies declined. In Dr. Hawkin's book, which was pub- 
lished in 1829, you will find that he strongly expressed his gratification 
and delight at the cheering prospect which lay before us ; and we were 



540 CLINICAL MEDICINE. 

all ready to sympathize in his anticipations, when, unfortunately, the cho- 
lera came, and brought us back to our original position. But to return to 
our subject. It is unnecessary for me to bring proofs in support of the 
opinion, that mercury alone brings on diseases of the bones. You are 
aware of the case of a man named William Byrne, in this Hospital, who 
got mercury for disease of the liver, and returned in a fortnight after he 
was discharged with periostitis. Dr. Lendrick had a case of poisoning 
by corrosive sublimate some time ago. The stomach pump, and white of 
egg, succeeded in saving the man's life, but he got a severe attack of 
periostitis. 

I shall now detain you for a short time in speaking of the treatment of 
periostitis. As to the local means, you will find much good from leeching, 
and blisters dressed with mercurial ointment, particularly when the disease 
is recent, and the inflammation circumscribed. I have also found the 
greatest benefit from mercurial inunction over the affected part. If the 
blisters produce but little effect, try the tartar-emetic ointment ; I have 
found it useful where blistering failed. In obstinate cases, Sir P. Cramp- 
ton's plan of cutting down to the bone may be had recourse to. When 
a periosteal node breaks and matter is discharged, and you observe the 
bottom of the sore covered with pale unhealthy granulations, or a piece 
of diseased bone lying in it which ought to be detached, introduce a stick 
of nitrate of silver, and touch, not the whole, but some given part of the 
surface every day, and you will produce a rapid improvement in its ap- 
pearance. This treatment was introduced by Mr. Nichol, and you will find 
a detail of it in the Edinburgh Med. and Surg. Journal deserving your atten- 
tive perusal. As to the general treatment of periostitis, where the constitu- 
tion is strong, and there is no objection to the use of mercury, this remedy, 
in the form of corrosive sublimate, affords a very certain and speedy relief, 
having premised venesection and leeching. Even when the disease arises 
after a course of mercury, or in consequence of syphilis, where its symptoms 
are violent and the constitution is strong, the rapid introduction of mer- 
cury is the best treatment you can adopt. This is particularly suited to 
that painful species of cranial periostitis which I have described, and 
which scarcely yields to any other remedy, and also to those cases where 
the disease attacks the shaft of the femur. In both of these affections the 
mercurialization, to be effectual, must be carried to decided salivation, 
and must be continued for three or four days after the mouth becomes 
sore, though you will meet some cases which yield before salivation. 
This, however, is an uncommon occurrence. Where the symptoms are 
less violent we may content ourselves with Plummer's pill or blue pill, in 
alterative doses. In persons of delicate habit, who are much worn out 
by disease, and where all other means fail, corrosive sublimate sometimes 
succeeds, or De Velno's vegetable syrup. The latter acts on the constitu- 
tion in a mild and beneficial manner, and I have seen many persons restored 
to health by its agency. We must never forget, however, that there is a 
material objection to the use of mercury in hospitals among the poor ; for, 
on returning home, they are almost invariably exposed to fatigue and 
cold, have consequently a strong liability to relapses, and are then of 
course worse than before. This unfortunate occurrence may be generally 
avoided among the wealthy, and to them the mercurial cure is therefore 
more applicable. Besides mercury, the most effectual remedies are 
colchicum and tartar emetic 3 but particularly hydriodate of potash. You 



PLEUROPNEUMONIA. 541 

will find, that after bleeding or leeching, by employing colchicum with 
narcotics, as, for instance, the wine or tincture of the seeds of colchicum 
with Battley's sedative liquor, or black drop, combined with magnesia, 
you will produce a very powerful effect. You are aware of the power 
which colchicum produces in subduing inflammatory affections of the 
heart, and also of the joints, and it must be looked on as a very valuable 
remedy. You have, in addition to this, the different antimonial prepara- 
tions. The antimonial wine and James's powder will be particularly 
serviceable. You cannot combine colchicum with antimonials, in conse- 
quence of their effect on the stomach, but you can combine either of them 
with narcotics. During the whole course of the disease you must employ 
narcotics ; they relieve pain, and are to be used plentifully, but with dis- 
crimination. When the disease becomes chronic, give sarsaparilla with 
nitric acid. The latter enhances the value of the sarsaparilla, though we 
are unacquainted with its modus operandi. You have, therefore, gen- 
tlemen, four modes of treatment, first the mercurial, which, where it is 
admissible, is the most speedy and effectual ; next, the antiphlogistic, 
consisting of bleeding, leeches, colchicum, antimonials, and narcotics : 
thirdly, the chronic treatment, which comprises sarsaparilla and nitric 
acid with narcotics, change of air, and time, and fourthly, that by hydrio- 
date of potash, either by itself, or what is better, combination with sar- 
saparilla. 

Postscript. — When these lectures were delivered in 1832-3, I was 
not so well acquainted with the great utility of hydriodate of potash, in 
periostitis, but I have since made most ample trial of it and am convinced 
that it possesses greater power over this, than almost any other disease. 
It is of extreme service in all forms of periostitis, whether arising spon- 
taneously, or as a symptom of syphilis, rheumatism, or abuse of mercury. 
The same rule should be observed, which was before laid down, namely, 
to increase the dose gradually, until a decided impression is made on the 
disease. 

I shall refer briefly to some points connected with the case of an old 
man in the chronic ward, who died lately of inflammation of the lung. 
At the period of his admission, he had been ill for some time ; both sides 
of the chest, but particularly the left, sounded dull on percussion ; he 
had extensive bronchial respiration and craehet rouille, in fact, it was a 
very bad case of double pneumonia, a disease which at his time of life is 
very seldom cured. W T e did all we could to arrest the progress of the 
disease ; we cupped him over the left side, gave him mercury so as to 
affect his system, and applied blisters to both sides of the chest, anteriorly 
and posteriorly. These were the only active measures which remained 
for us to employ ; from the man's age, the weakness of his pulse, and the 
duration of the disease, we could not venture on general bleeding ; we 
could only attack the disease with local depletion, mercury, and counter- 
irritation. All these remedies were applied with great diligence, but 
unfortunately proved incapable of checking the disease. His cough con- 
tinued, respiration became more difficult, and though his mouth became 
affected, the dulness on percussion increased day after day ; and though 
the patient was removed into a warmer room, and every attention paid 
to his comfort, it was evident that he was getting gradually worse. About 



542 CLINICAL MEDICINE. 

a fortnight after his admission, his expectoration assumed the ptirulent 
character, and it was obvious that the lung had passed from the stage of 
hepatization into that of interstitial suppuration. He took the decoction 
of polygala, wit]? Iceland moss and syrup of white poppies, but without 
any relief to his symptoms ; the disease increased, and he died on the 
nineteenth, sixteen days from the date of his admission. 

On examining the lung, the ordinary phenomena of pneumonic inflam- 
mation were discovered ; parts of the lung were in the state of grey he- 
patization, others were infiltrated with pus, and broke down easily under 
the finger. We found, too, that he had not only pneumonia, but also 
extensive pleuritis and pericarditis. The pleurisy had probably com- 
menced about eight or nine days before his death ; the pericarditis was of 
an origin somewhat more recent. 

You may ask why I did not recognise these affections before death. 
The reason is twofold. The man was in a very weak and hopeless con- 
dition, and both sides of his chest were sore from the blisters ; these are 
circumstances under which I have strong objections to torment a patient 
with examinations, and therefore I made none in this case. The other 
reason is, that in a patient who has been greatly reduced by some acute 
disease, new inflammations are apt to spring up with great rapidity, and 
with still greater latency. I remember a very remarkable case of the 
same description which occurred at the Meath Hospital, where the patient 
had a very extensive inflammation of the pleura with exudation of lymph 
and effusion of a considerable quantity of fluid, and yet not one of these 
symptoms was recognised during life. This man, you will recollect, 
never complained of pain in the side, nor had he orthopnoea, irregularity 
of pulse, lividity of countenance, or any of those symptoms which are 
looked upon as indicative of pericardial inflammation, yet on dissection 
we find the pleura extensively engaged, lymph exuded on its surface, 
and a small quantity of sero-purulent effusion in its cavity ; and on ex- 
amining the heart, we find the pericardium covered internally with an 
extensive gelatinous layer, consisting of lymph and puriform fluid inti- 
mately mixed together. You perceive, then, in this case, a confirmation 
of what I have so often insisted on, that pleuritis may occasionally run 
through its course, unaccompanied by pain in the side, and that inflam- 
mation of the pericardium may exist without orthopnoea, irregularity of 
pulse, lividity of countenance, or fainting, symptoms formerly believed to 
be more or less manifest in every case of pericarditis. The pathology of 
pericarditis has been investigated but lately with the care it deserves : 
the labours of our French brethren have been mainly instrumental in pro- 
ducing its present degree of advancement. In England some valuable 
observations have been contributed by Dr. Elliotson and others, but they 
have been more than rivaled by the contributions to the diagnosis of this 
disease, which have appeared in the Dublin Medical Journal. 

To return to our subject. Pericarditis is a disease of quite as frequent 
occurrence as pleurisy, and often, as in the present instance, associated 
with the latter ; on the whole, I do not consider pericarditis as more dan- 
gerous or more difficult to cure than pleuritic inflammation, neither does 
its existence seem less easily ascertained. Some cases, it is true, are 
extremely insidious in their nature, but the same may be said of cerebri- 
tis, pneumonia, and all other phlegmasise ; usually, however, a careful 
and attentive physician will at once detect the existence of pericardial in- 



PLEUROPNEUMONIA. 543 

flammation. When he finds that a patient has been exposed to causes 
capable of exciting fever, that he has been liable to gout or rheumatism, 
or has been actually attacked with either, then will his attention be 
directed to the heart ; if he perceives that its action is either unusually 
violent or irregular, or if he observes that uneasiness and oppression of 
chest are complained of to a degree not to be accounted for by any pul- 
monary lesions present ; if he finds that his patient has the appearance of 
a person labouring under some serious disease, and that none such exists 
in the lungs themselves, then will he be called on to examine the region 
of the heart with the greatest accuracy. One of the most common symp- 
toms of pericarditis is tenderness in the intercostal spaces over or near the 
heart. This is not perceived in many cases until pressure is made with 
the fingers. Tenderness occurs in many who do not complain of pain 
or stitch in this portion of the chest; when the latter coexists with ten- 
derness, the presumption in favour of the presence of pericarditis is still 
greater. The pain and uneasiness about the heart, are, as Dr. Elliotson 
remarks, generally increased by pressing in the left hypochondrium, up- 
wards towards the diaphragm. I must refer you to Dr. Stokes's and Dr. 
Mayne's papers for any analysis of the physical signs derived from per- 
cussion and auscultation, and also for an explanation of the reasons why 
the general symptoms are subject to such striking variations in this dis- 
ease. In some you have, soon after its commencement, lividity, ortho- 
pnoea, and tendency to fainting, combined with irregularity of pulse ; in 
others the disease runs its w T hole course, whether it terminates fatally or 
in health, without any of these symptoms ; in fact, no disease is more 
inconstant in its characters, and none more requires the aid of investiga- 
tion by means of physical signs, which, if well-conducted, seldom fails to 
clear up all doubts. Of one thing I am certain, that inflammation of the 
pericardium in a person of tolerably good constitution' may be generally 
arrested in its progress by bleeding, frequent leeching, and scruple doses 
of calomel. It is mere trifling on such occasions to have recourse to tar- 
tar emetic, digitalis, or the common antiphlogistic remedies. Instantly 
use every effort to produce the full action of mercury on the system. 
Apply the ointment to the axillae ; smear it over the inside of the thighs ; 
make your patient respire the vapour of hydrargyrum cum cretd as often 
in the day as he can bear the process, and be assured that you are pursu- 
ing the proper course. Well has it been observed by Dr. Elliotson, when 
speaking of a fatal case of pericarditis, — " The only chance I had to save 
the life of this person would have been to have pushed the mercury fur- 
ther. I am quite sure that more lives are saved in inflammatory diseases 
by carrying mercury to a great extent, than by merely having recourse to 
it for the simple production of ptyalism." It is the want of decision in 
the practice of the French physicians — it is to their want of confidence in 
mercury, that we must attribute the greater mortality of pericarditis in 
Paris than in Dublin ; for most of our patients recover, most of theirs die. 
Of course, gentlemen, the most unfavourable of all cases is where peri- 
carditis attacks a person debilitated by previous sickness, such as fever, 
dropsy, &c. Here the disease runs a very rapid, and too often a fatal 
course, and cannot be controlled. One practical remark, and I have 
done. Before effusion takes place into the pericardial sac never apply a 
blister ; after it has occurred, repeated and severe blistering over and 
about the region of the heart is one of our best remedies. 



544 CLINICAL MEDICINE. 

Two years ago I had an opportunity of studying a case which subse- 
quently proved to be an example of inflammation of the muscular sub- 
stance of the ventricles, ending in suppuration and the formation of a large 
abscess in the ventricular parietes. This is a very rare occurrence, for 
the simple reason, that inflammation of the substance of the heart generally 
proves fatal before pus is formed. A very robust gentleman, aged fifty- 
five, from the neighbourhood of Wicklow, came to Dublin for the benefit 
of advice. He had complained of cough for many months, together with 
dyspnoea and palpitation of the heart ; latterly he had become anasarcous, 
and suffered much from distress and pain referred to the region of the 
heart. This pain formed the chief subject of his complaint, and darted 
over the chest. On examination, I immediately detected hypertrophy 
and dilatation of both ventricles, and I announced the existence of val- 
vular disease, inasmuch as a loud and extensive bruit de soufflet existed, 
together with a remarkable fremissement cataire, and a very irregular 
pulse. This opinion was delivered in the presence of Dr. Sherwood and 
Mr. Hetherington. Our patient returned to the country, where he con- 
tinued to complain of pain in the heart that was at times excruciating. 
He died suddenly at the end of a few weeks. The results of the post- 
mortem examination were kindly communicated to me by Dr. Sherwood. 
Considerable dropsical effusion into both pleural cavities ; heart exceed- 
ingly enlarged. " On slitting open the pericardium, I found (says Dr. 
Sherwood) that the heart adhered to its entire surface by means of bands 
of coagulable lymph, which were easily broken down except at the apex 
of the heart, where they were very strong and firm. In attempting to 
break them, more than two ounces of purulent matter escaped into the 
cavity of the pericardium, which caused me to institute a very close ex- 
amination of the parts, in order to discover whence the pus came. I 
found a small rent in the apex of the heart, immediately below the floor 
of the left ventricle, exactly in the situation of the firm adhesions before 
spoken of. On enlarging this opening, I discovered a cavity in the sub- 
stance of the heart, with a regularly-defined wall, capable of containing 
more than two ounces of fluid. The walls of both ventricles were enor- 
mously thickened ; all the valves were more or less affected ; but the 
chief disease lay in. the semi-lunar valves of the aorta, which were nearly 
altogether ossified." 

This case was extremely remarkable, and exhibits an example not 
merely of the dropsy and dyspnoea which so usually attend hypertrophy 
and valvular disease of the heart, but also of a combination of chronic 
pericarditis and chronic inflammation of the muscular substance of the 
ventricles, ending in the very rare termination, — abscess. 

Having made these observations, I shall next call your attention to the 
disease of Francis Thorpe, which is important both in itself and from the 
circumstance of such cases being frequently met with. This lad, who 
was much exposed to the weather, being an outside servant, was attacked 
about six months ago with cold, followed by hoarseness and sore throat, 
with cough, then slight, but at present rather troublesome. A certain 
degree of rawness about the fauces was observed soon after the attack, 
and latterly the sub-maxillary glands have become slightly enlarged. On 
looking into the throat, the velum and fauces appear redder than natural, 
the amygdalae are swollen, and the mucous membrane covering the back 
and sides of the pharynx is dry, and covered with irregular superficial 



CHRONIC LARYNGITIS. 545 

excoriations. The hoarseness still continues, and he can only speak in 
whispers. His general health, however, does not seem in any degree 
impaired ; he has no fever, his appetite is good, and his sleep natural. 

This case, however, is one which demands particular attention. A 
boy is attacked with cold ; he gets slight local inflammation of the fauces 
and larynx ; this produces cough and hoarseness, which go on for months 
rather increasing than diminishing, and his symptoms finally assume a 
chronic and intractable character. Still he does not fall away in flesh, 
has no symptom of hectic, and, on examining his chest, you cannot find 
any evidence of the existence of tubercles. In making the prognosis in 
such a case, you should always act with great caution. Though an ex- 
amination of the chest should detect no distinct sign of tubercles, and a 
review of the state of the constitution should satisfy you that there was 
no fever, night-sweats, or wasting of flesh, yet the obstinacy and persist- 
ence of the inflammatory condition of the larynx and fauces would seem 
to show that the affection, though not decidedly of the scrofulous charac- 
ter, was still very analogous to it, and might end in phthisis. You should 
not be so sanguine as to anticipate a certain cure, because the cough and 
laryngeal symptoms are unaccompanied by fever, or by stethoscopic phe- 
nomena, indicating the approach of phthisis. The disease, by fixing itself 
in the larynx, and keeping up a constant irritation in the neighbourhood 
of the lungs, would probably, after some time (if exacerbated by fresh 
colds, and confirmed by neglect), give rise to tubercular development. 

Allow me to allude here briefly to a form of chronic laryngeal inflam- 
mation which has been described under the name of phthisis laryngea. 
Of this disease there are two varieties. In one case the hoarseness and 
sore throat follow the development of tubercles in the lung ; in the other 
they precede it. Consumptive persons very frequently get, shortly after 
the occurrence of scrofulous inflammation of the lungs, sore throat, hoarse- 
ness, and laryngeal cough. But this is different from the hoarseness and 
cough which precede phthisis. In the former, the laryngeal symptoms 
are secondary, and form only a part of the general disease ; in the latter, 
they constitute the first link in the chain of morbid action. The former 
take place only in a constitution decidedly scrofulous ; the latter occur 
most commonly in constitutions which have been impaired by various 
debilitating causes, and thereby rendered analogous to, or identical with, 
the scrofulous. One disease, however, explains the other; for it is clear 
that if a certain state of the constitution is capable of occasioning scrofu- 
lous inflammation of the lungs and tubercular development in the pulmo- 
nary tissue, in the first instance, and laryngeal disease in the second, it is 
clear, I say, that the order of succession may be very easily inverted, and, 
that in such a constitution, the accidental circumstance of a cold falling; 
on the larynx, may determine the appearance of disease in that part long 
before the lungs become engaged. Hence, whenever you are called on 
to treat a case of chronic laryngitis, where the disease has lasted for any 
length of time, and where the patient's system has been impaired by any 
debilitating cause, or where you have any reason to suspect that he is of a 
strumous diathesis, your prognosis should be always guarded. 

You should not, however, give up the case at once ; particularly if an 
examination of the chest assures you that there is no scrofulous deposition 
going on in the lung. In the first place, endeavour to remove the inflam- 
mation of the throat, if possible ; by doing this, you will accomplish a 
36 



546 CLINICAL MEDICIx\E. 

vast deal ; and in the next, you should direct all your efforts towards im- 
proving the state of the constitution ; for in this way you make the greatest 
progress in checking the tendency of the individual to scrofula. If there 
be much tenderness of the larynx on pressure, as you can easily ascertain 
by placing your finger and thumb on each side of the ihyroid cartilage, 
pressing the larynx backwards, and moving it from side to side, you 
should commence with the local detraction of blood. A small number of 
leeches should be applied to the throat every second or third night, and 
this should be continued for a week or fortnight. If there be no tender- 
ness of any amount, and the patient can bear pressure freely, there is no 
necessity for applying leeches. Your means must then be confined to 
those remedies which act immediately on the diseased mucous surface, 
and for this purpose, one of the best applications is a solution of nitrate 
of silver, ten grains to the ounce, or a solution of the sulphate of copper, 
in the same proportions. The best mode of applying it is to take a pro- 
bang, or a small piece of sponge, fastened to the end of a quill, dip it in 
the solution, and having slightly squeezed it to prevent, the fluid from 
dropping, touch the excoriated and red parts of the fauces as far as you 
can conveniently go, rather by pressing the sponge gently against the 
inflamed mucous membrane than by rubbing. It will be essentially neces- 
sary to touch every portion of the diseased surface of the pharynx ; for if 
any part be omitted, it will have the effect of keeping up the disease. 
You perceive the object here is to change the action of the mucous mem- 
brane. By acting powerfully in this way on the mucous membrane cover- 
ing the pharynx, fauces, and entrance of the larynx, you will often suc- 
ceed in bringing on a healthy action, which spreads to the parts in the 
vicinity. Of this we have an illustration, afforded by the results of treat- 
ment in chronic diseases of the skin, where local applications to a par- 
ticular part not only cure that part, but also extend their influence to a 
considerable distance on every side. It is the same with respect to irri- 
tation or inflammation of the lower part of the digestive tube ; the use of 
astringent injections, which can only affect the lower part of the rectum, 
is often found of essential service in relieving dysenteric affections of the 
colon. 

In addition to the use of the nitrate of silver, we have employed a 
remedy in this boy's case, which has been found beneficial in several 
instances where no sign of pulmonary irritation is present — I allude to the 
use of iodine inhalations. This was also intended to make a still further 
change in the condition of the diseased mucous membrane. It is made 
by putting from five to ten drops of the tincture of iodine with half a 
drachm of tincture of conium, and four ounces of hot water into an 
inhaler, and making the patient draw the vapour into his throat for about 
ten minutes, every night and morning. This form of inhalation proved 
extremely serviceable in the case of a gentleman who has attended my 
lectures this winter. About the commencement of November, while in a 
delicate state of health, he was attacked with cold, and got sore throat, 
followed by slight huskiness of voice, and hard, incessant, laryngeal 
cough. These symptoms continued during December and the greater 
part of January, and were not completely removed until the beginning of 
February. He had considerable rawness of the back and sides of the 
fauces and larynx ; we observed that the mucous membranes of those 
parts had a strong tendency to become excoriated ; «for whenever an exa- 



CHRONIC LARYNGITIS. 547 

cerbation of his symptoms occurred, and that his cough in the morning 
was harder than usual, small portions of the detached pellicles of lymph, 
exuded by the mucous membrane, came away at each fit of coughing, 
and his sputa were tinged with blood. There was another symptom in 
this case, which you will very frequently meet with in similar instances, 
namely, a remarkable feeling of chilliness in the integuments of the fore' 
part of the neck and external fauces. This he was in the habit of remark- 
ing, and could always foretell the occurrence of an exacerbation of his 
laryngeal symptoms, by the increased feeling of cold in the cutaneous 
surface over the diseased parts. In this case a great deal of good was 
effected by the inhalation of iodine with conium. The mode in which 
this gentleman employed it was by dissolving from six to nine grains of 
the extract of conium in hot water, and then adding the tincture of iodine. 
Instead of the common inhaler, which contains but a small quantity of 
fluid, and in which the inhalation becomes cold in a very short time, he 
employed for the purpose a high old-fashioned teapot, which contained a 
large quantity of fluid, and could be used for a much longer period. 
Under the use of this, with counter-irritation, and the internal use of 
iodine with sarsaparilla, the laryngitis disappeared. It returned, however, 
about a month afterwards on fresh exposure ; but was speedily removed 
by the use of the nitrate of silver solution. 

Another thing which we have prescribed for this boy, and which proves 
an excellent adjuvant in the treatment of such cases, is counter-irritation 
by croton-oil frictions. To an ounce of compound camphor liniment, we 
add twenty or thirty drops of croton oil; and of this lotion about one or 
two drachms are to be rubbed over the parts, night and morning, until the 
eruption appears. Two rubbings are generally sufficient to produce a 
copious eruption of papulae, about the size of a pin's head, and having 
exactly the appearance of a disease at present very rare — the eczema mer- 
curiale. 

We have not, however, been able to effect any remarkable improvement 
in this boy's symptoms, by the means to which I have just now alluded; 
and the question is, what other remedies have we left from which we 
could hope to derive any advantage? The boy has no fever or emacia- 
tion; his appetite is good, his sleep regular, and the stethoscope informs 
us that there are no symptoms of tubercular development; we are, there- 
fore, I think, authorised in attempting to arrest the disease by the only 
means of which we have a choice under such circumstances. It is my in- 
tention to attempt its removal by mercury, and I have therefore ordered 
him to take, three times a-day, half a grain of calomel, three grains of blue 
pill, with a grain of the extract of conium; and instead of iodine, we have 
directed him to inhale the vapour of hydrargyrum cum creta twice or three 
times daily. If, however, we find that this does not produce speedy im- 
provement of his symptoms, we shall stop it immediately, as the use of 
mercury in such cases is generally a perilous experiment. I shall also take 
care to pay attention to the general state of his health, as this is a matter 
of great importance in cases of chronic diseases. I had almost forgotten 
to observe, that in such cases the use of the decoction of sarsaparilla with 
nitric acid has been found extremely beneficial. There is one point in 
the treatment of chronic laryngitis which you should never forget — and 
that is, to make the patients refrain as much as possible from speaking. 
Unless they do this, you will find it very difficult to effect a cure. A per- 



548 CLINICAL MEDICINE. 

son with an inflamed larynx, who exercises his voice as usual, acts as 
foolishly as a man who reads with inflamed eyes, or walks with a sprained 
ankle. The only thing I have to add with respect to the treatment of this 
disease is, that the patient should be kept as much as possible in an equal 
temperature, and hence it will be necessary, in many instances, to confine 
him to the house, or at least to prevent him from exposing himself to a 
cold and damp atmosphere. When he recovers, he should use cold gar- 
gles and cold lotions to the throat, in order to render the parts less suscep- 
tible of cold. 

Allow me now to direct your attention to two cases of prurigo which 
have been recently admitted. The first is that of Jane Cassady, a woman 
advanced in life, but of tolerably good constitution, considering her age, 
station, and circumstances. About three months before admission, a rash 
appeared over her arms, legs, and body, which was preceded and accom- 
panied by pain of the stomach, head, and limbs, with recurring rigors. 
As far as we can learn from her description, this appears to have been 
urticaria; of this, however, we cannot by any means be certain; and be- 
sides, it is of little consequence, as prurigo may come on without it. She 
is at present labouring under prurigo senilis, not thickly disseminated, but 
still a source of constant annoyance to her from the intolerable itching it 
produces. Several of the papulse have formed dark red crusts, but this 
is in consequence of their bleeding from being scratched. 

This affection has been so well described by writers on cutaneous dis- 
eases, and is so easily recognised, that I shall not take up your time in 
detailing its characters: a few circumstances connected with treatment, 
however, should be mentioned as deserving your notice. In the first place, 
I may observe that prurigo is a most harassing complaint, and, if not 
checked, has a tendency to undermine the constitution by disturbing the 
patient's rest. The warmth of the bed-clothes, by increasing the vascu- 
larity of the skin, occasions an aggravation of the symptoms ; the patient 
passes a miserable and restless night, and rises in the morning quite un- 
refreshed. This, in process of time, gives rise to a kind of febrile condi- 
tion of the system; the mouth and fauces become dry ; the appetite is im- 
paired; the secretions deranged, and debility and emaciation gradually 
produced. It is a disease which has broken many a constitution, which, 
previous to its accession, was to all appearance unimpaired and healthy. 

Prurigo has been confounded with common itch, but if you examine 
the parts it occupies, you will easily distinguish them. It is most likely 
to be confounded with the small vesicular itch, where the vesicular papulse 
(this is the most expressive term I can think of) are extremely minute. 
There is a papular itch, and there is also one which is intermediate 
between the vesicular and the papular ; it is with the latter that prurigo 
is most apt to be confounded. The difference between them, however, 
may be recognised by observing the parts of the body on which they 
appear. Itch generally attacks the extremities, and particularly the inside 
of the joints and the spaces between the fingers. Prurigo, however, does 
not occupy the same situations. If you examine this woman, you will 
not be able to find any trace of the eruption about the joints or between 
the fingers — and this circumstance is of itself sufficient to make the dis- 
tinction, for itch would not have lasted for three months without attacking 
these parts. I may also observe, that prurigo senilis is generally accom- 
panied by derangement of some of the important secretions of the body, 



PRURIGO. 549 

but particularly of the urine. Its appearance is in many instances pre- 
ceded by a scanty flow of urine, and it is frequently accompanied by the 
deposition of a copious whitish sediment, which is the lithate of ammonia. 
This observation is worthy of attention, because it furnishes us with a hint 
towards the treatment, of which we may sometimes avail ourselves with 
great benefit to the patient. You will, in such cases, often effect a great 
deal by the use of diuretic medicines — as cream of tartar with decoction 
of juniper berries and squill ; or with the more stimulant diuretics — as 
turpentine and cantharides. It will be also good to vary these remedies 
according to the circumstances of the case, and they should be always 
given in combination with medicines calculated to act beneficially on the 
digestive organs. In this case, we have given decoction of sarsaparilla 
with nitric acid for the last two days ; before this we gave cream of tartar 
with powdered bark. These are some of the best medicines which can 
be used internally in the treatment of prurigo senilis. It is, however, a 
very obstinate disease, and you will be often obliged to try many internal 
and external remedies before you can hit on one that will prove service- 
able. Cooling diuretic aperients, aperients combined with tonics, and 
the decoction of sarsaparilla with nitric acid, — these are the chief internal 
remedies ; as to external ones, they are extremely numerous. In the 
present case we have, in the first place, directed the patient's body to be 
washed with a lather of soap and warm water every night and morning. 
The water for this purpose should be used as hot as the patient can bear 
it, and a very soft brush or sponge should be employed. In prurigo, a 
vast deal of good has been done by merely washing the itchy parts with 
soap and warm water ; how it acts I cannot say, but I have seen a great 
deal of advantage derived from a long-continued perseverance in its use. 
After this you may have recourse to more powerful applications — such, 
for instance, as sponging the parts at bed-time with hot whiskey and 
laudanum, a pint of the former to a drachm of the latter. Here you have 
the stimulant effect of the whiskey, the narcotic of the laudanum, and the 
peculiar action of heat on the skin, all combined, and calculated therefore 
to make a very decided impression. How this effect of heat is produced 
I cannot tell, but we all know that, whether applied in a moist or dry 
form, it exercises a powerful influence over the vascularity and nervous 
vitality of the skin. Neither can I tell you what description of cases are 
most likely to benefit by it ; some cases of prurigo senilis are much 
relieved by warm applications, others are not; you should, however, 
always make a trial. 

There w r as one application used in this woman's case, to which I shall 
briefly call your attention. A drachm of acetate of lead was dissolved in 
two ounces of wine vinegar mixed with the same quantity of water, and 
this was rubbed up with olive oil so as to form a liniment. Mr. Nalty, 
who mixed up the ingredients, says that three ounces of olive oil were 
absorbed. You are aware that oil conducts itself, with respect to the 
metallic oxides, as it does with the ajkalies. This formed a liniment, 
which, when allowed to stand, separates; but its ingredients are at once 
miscible by shaking the bottle. From its use the woman has derived 
great relief, and I can recommend it to you as one of the best applications 
in prurigo. 

Before I conclude this lecture I shall allude briefly to the very inte- 
resting case of Sarah O'Neil. This young woman was admitted on the 



550 CLINICAL MEDICINE. 

17th of February, having been attacked, on the 10th, with fever of the 
ordinary type. On the day after her admission, she complained of want 
of sleep, and pain of the forehead and temples ; but she had no raving, 
tinnitis aurium, intolerance of light, or other symptoms of inflammation 
of the brain. She had been confined about a fortnight before she came 
in, and complained that her breasts were very troublesome to her. Her 
belly was soft and fallen, quite free from tenderness or soreness, and she 
stated that her bowels were free. Her tongue was furred, her pulse 130, 
the lochia suppressed for the last two days. Things went on tolerably 
well for four or five days, when her belly became tympanitic, and she 
began to complain of pain on pressure. The action of the heart now 
became more violent ; her pulse rose to 140, and blood began to appear 
in her stools. On the 24th of February — that is to say, about the four- 
teenth day of her illness — her pulse was 150 ; she passed a large quantity 
of blood from the bowels, and the tympanitis subsided. 

In cases of fever accompanied by tympanitis and signs of intestinal 
congestion, hemorrhage from the bowels, particularly when it occurs on 
one of the critical days, should not be interfered with. It is in this way 
that nature very frequently brings about relief of the congestion and irri- 
tation of the gastro-intestinal mucous membrane, just as she relieves con- 
gestion of the head by bleeding from the nose. In the case of a lady 
whom I attended along with Mr. Palmer, some time ago, at Drumcondra, 
the occurrence of intestinal hemorrhage was followed by the most marked 
effects; her belly became soft, the tympanitis disappeared, and all her 
febrile symptoms were speedily removed. The appearance of blood, 
therefore, at such periods and under such circumstances, is to be looked 
on as a favourable occurrence ; nor should it be interfered with in any 
way until, from its continuance or its quantity, it appears likely to produce 
debilitating effects. In the present case, however, this hemorrhage will 
require to be very carefully watched. The woman's system is that which 
is favourable to profuse fluxes of blcod, for it is not long since her ac- 
couchement, and she has had suppression of the lochia. She has had but 
little fever for the last two or three days, but the action of the heart still 
continues extremely violent, and her pulse is still rising. Respiration, 
too, has been considerably accelerated ; and, where this occurs, you have 
always reason to apprehend danger. I have accordingly endeavoured to 
moderate the hemorrhage by the use of acetate of lead and opium. A 
draught composed of two grains of acetate of lead, eight minims of tinc- 
ture of opium, and fifteen minims of wine vinegar in six drachms of water, 
has been prescribed to be taken as occasion requires. A large blister has 
been applied, so as to cover the epigastrium and sternum, and she has 
been allowed port w 7 ine and chicken- broth. Where a patient, debilitated 
by previous fever, has been attacked with hemorrhage, you should be 
careful in supporting the system by small quantities of wine, and light 
nutritious food ; for there is always more or less danger to be apprehended 
of a sinking of the powers of life. . In cases of this kind the cautious use 
of acetate of lead, with opium and wine, are the only means on which we 
can rely with any confidence. 

A man was admitted into the chronic ward a few days ago who cannot 
separate the lower from the upper jaw to the distance of more than two 
lines. What are the cases in which we find this immobility of the lower 
jaw ? Most commonly in tetanus or locked-jaw ; but here this cannot be 



PRURIGO. 551 

the case, for the man has no sign indicative of a tetanic affection, no rigi- 
dity of the muscles of the neck ; his countenance is very different from 
that of a tetanic patient, and he has not been exposed to any of the ordi- 
nary exciting causes of that disease. But leaving all consideration of the 
nature of the disease out of the question, what is it that prevents him from 
moving his lower jaw ? It must depend on one of two causes ; either the 
muscles which perform the motions of the lower jaw are stiff, rigid, and 
incapable of motion, or else there is some disease of the articulation which 
obstructs the motion of the bone. This proposition is universally true of 
all articulations, that when they become impeded or completely obstructed 
in their motions, the derangement arises from some abnormal condition of 
the muscles, or of the bones and ligaments which form the joint. 

In this case we find, that, in addition to being unable to perform the 
proper motions of the lower jaw, the patient has intense pain, darting 
from the angle of the jaw towards the temple, the ear, and the side of 
the neck. This pain is of an extremely violent character, so as to re- 
semble tic douloureux, and the resemblance is still farther increased by 
its being more or less intermittent. Now, on inquiry into the history of 
this case, we find that the patient had some time ago laboured under 
toothache, for which he got the last molar tooth but one of the upper jaw 
extracted, and that immediately afterwards he was seized with violent 
pain in the part, and found that he could no longer move his lower jaw 
as usual. I have seen many cases of this kind, in which a painful or 
carious tooth, or an injury done to the gum or jaw T , has been followed by 
violent darting pain in the nerves of the face, simulating in many parti- 
culars tic douloureux. J remember being sent for to Middleton, near 
Cork, some time since, to see a young lady of delicate constitution, whose 
health was materially deranged from what was said to be an attack of tic 
douloureux. She had been under the care of many practitioners, and had 
used very large doses of the carbonate of iron and sulphate of quinine, 
and at the time I visited her was taking arsenic. The first thing I did 
on my arrival was to examine her teeth. On close inspection I observed 
that on the crown of one of the upper molar teeth there was a spot which 
appeared to be decayed, and found on inquiry that she had frequently 
suffered from pain in this spot when she drank any cold liquid. I had 
the tooth drawn and soon afterwards the pain completely ceased. Yet 
in this case the pain was not only of an intense character, preventing 
sleep and wearing out her strength, but it had its intermissions, and was 
aggravated at particular hours of the day. Another instance of the same 
kind came under my notice about twelve months ago. A young lady 
was brought to me by a medical friend of her's to have my advice for an 
attack of tic douloureux. She had been attended by this gentleman with 
great care, and no mode of relief left untried, for her sufferings were in- 
tense, and she had constant exacerbations of pain. I asked him, were 
her teeth sound, or had she any disease of the gum or jaw ? He said not, 
and that he was sure of this, for he had examined her teeth over and over 
again. On opening her mouth, however, I thought I saw some appear- 
ance of unsoundness in one of her teeth, and recommended her to go to 
Mr. M'Clean and get it drawn. She did so, and the pain quickly dis- 
appeared. I could also give many cases in which an injury done to some 
of the branches of the dental nerve has given rise to symptoms closely 
resembling those of the tic douloureux. One of the most curious circum- 



552 CLINICAL MEDICINE. 

stances connected with such cases is, that the pain is always of a more or 
less intermittent character. The same thing is observed in that form of 
headache which arises from irritation of the brain, produced by spiculse 
of bone growing from the internal table of the skull. In a case which 
occurred some time back at the Meath Hospital, where several spiculae, 
some of them more than a quarter of an inch in length, were pressing on 
the brain, the headache was of a distinctly intermittent character. This 
remarkable periodicity of exacerbation, in cases where the operation of 
the exciting cause continues still the same, seems to be peculiar to the 
nervous system. 

In many cases considerable derangement of the facial nerves is found 
to follow an injury done to some branch of the dental nerve in drawing a 
tooth. When the bone has been injured by the force used in extracting 
the tooth, it frequently happens that, if the injury be not quickly repaired, 
and the parts healed up, symptoms resembling those of tic douloureux or 
rheumatic neuralgia will supervene, and give the patient a great deal of 
annoyance. Such was the origin of the mischief in the Case before us ; 
the man received an injury of the upper jaw in drawing a tooth which is 
not as yet healed, as you may perceive by introducing a probe betw r een 
the separated portions of gum, when you will find it grate against the 
rough surface of the bone. In addition to this, there is considerable ten- 
derness of the gum and swelling of the neighbouring parts, which have 
extended to the muscles, their sheaths, and finally to the articulation of 
the lower jaw. You can satisfy yourselves of this by examining the parts 
and striking the lower jaw, so as to press it suddenly upwards and back- 
wards into the glenoid cavity, just in the same way as you press the thigh 
bone against the acetabulum when you wish to ascertain whether there is 
inflammation of the hip-joint. The motion of the lower jaw is here pre- 
vented by inflammation, extending from the upper jaw so as to involve 
its ligaments and the neighbouring muscular sheaths. There are other 
causes, also, which may be attended with the same diminution of motion 
in the joint. Thus a man may get an attack of rheumatism in the scalp, 
which may extend to the temporal muscles and prevent him from being 
able to depress his lower jaw, and I have known cases in which this con- 
dition of the temporal muscle has given rise to suspicions of the existence 
of trismus. When you examine the articulation you find nothing amiss, 
but when you come to press on the temporal muscle above the zygoma, 
the patient complains of pain and tenderness. The irritation produced 
by rheumatic inflammation gives rise to a fixed rigid state of the muscle, 
and hence the patient cannot open his mouth. This form of disease I 
have described lon^ since, in a paper published in the Dublin Hospital 
Reports. It can be relieved with great ease by applying leeches to the 
temple, and ordering the patient to rub over the part a small portion of 
mercurial ointment with extract of belladonna, two or three times a-day. 
The same state of the temporal muscle is sometimes observed as resulting 
from an extension of inflammation, in case of a wound of the scalp in its 
vicinity. 

In the case before us, almost every thing will depend on the process 
which nature may adopt with respect to the injury of the maxillary bone. 
If the bone throws up healthy granulations, and the inflammatory process 
ceases, the affection of the nerves, as well as of the muscles and joint, 
will quickly subside. All we can do under the circumstances is to apply 



JAUNDICE WITH ARTHRITIS AND URTICARIA. 553 

leeches over the side of the face, and order the man to rub in mercurial 
ointment ; every thing, however, will depend on the turn the disease of 
the bone may take. 

I wish to make a few observations on a case of jaundice in the small 
chronic ward. I do not intend to enter into any particular inquiry con- 
cerning the causes of this disease ; you are aware that it may depend upon 
many causes, upon affections of the mind, gastro-duodenitis, inflammation 
or abscess of the liver, the presence of gall-stones, diseases of the head of 
the pancreas, aneurism of the hepatic artery, and, what is more remark- 
able, in some cases may arise without any assignable cause whatever. 
In the present instance it seems to have been the result of acute hepatitis. 
The man was attacked with symptoms of inflammation of the liver, and 
about a fortnight afterwards became jaundiced. It is unnecessary for me 
to draw your attention to the history of the case, or the present state of the 
patient ; all I shall do at present is to make a few remarks on some points 
of treatment. 

In the first place, the jaundice is, as you perceive, of an intense cha- 
racter : the man is as yellow as he could be. Now this I look upon as a 
favourable sign ; the deeper the colour is in recent cases the greater is 
the chance of effecting a cure. There are no cases so intractable as those 
in which the tinge of yellowness is so faint that you would be likely to 
overlook it, as in the case of a man in the chronic ward, in whom the 
colouring is so slight, that it requires some attention to ascertain whether 
he is jaundiced or not. Such a case as this is always of a chronic, intrac- 
table character, and this is too frequently connected with a scirrhous state 
of the liver. Again, in this man's case we cannot detect any appearance 
of bile in the evacuations ; this is another good sign. When jaundice 
coexists with bilious stools, the prognosis is, generally speaking, bad." A 
but slight tinge of yellowness of skin, and the continued presence of bile 
in the stools, are two circumstances which I always look upon as indica- 
tive of an unmanageable and frequently incurable affection. It {generally 
depends on a scirrhous state of the liver, or some organic derangement 
beyond the power of medical treatment. Again, another good si£>n in 
jaundice is, that as long as the bile is absent in the stools it should be 
present in the urine. If a patient labouring under jaundice has clay- 
coloured stools, and you find on examination that his urine becomes 
heavily laden with it, it is a very favourable circumstance, for it shows 
that, although the usual channel for the exit of bile from the system is 
stopped up, nature has provided a remedy for the evil by establishing an- 
other emunctory. You can understand then the reason of the anxiety I 
felt at finding that this patient's urine was becoming paler and diminish- 
ing in quantity, at a time when bile was not present in the stools. In 
acute cases of jaundice, you should always bear in mind that patients 
will sometimes have a complete suppression of the biliary discharge, fol- 
lowed by coma, without any symptoms of disease of the brain. Why 
this occurs in some and not in all eases we cannot understand, but, from 
whatever cause it may arise, we find that in some instances jaundiced 
patients become stupid and lethargic, and die in a state of confirmed 
coma. In such cases there is always very great danger, and where coma 
has appeared as a prominent symptom of jaundice, you should always 
give an unfavourable prognosis. I have never seen but one patient re- 
cover under such circumstances. On the other hand, it is equally curious 



554 CLINICAL MEDICINE. 

that derangement of the urinary system is one of the most common symp- 
toms of disease of the brain. You will therefore understand the cause of 
my alarm, when I observed a diminution of the urinary secretion in this 
patient. As soon as I perceived this symptom, though the patient had 
been taking mercury, and was improving at the time, I immediately a 
ministered a diuretic, and this fortunately succeeded in producing a co- 
pious flow of urine. We prescribed the following diuretic, which had 
not been taken for niany hours when it produced a decided determination 
to the kidneys: — 

R. Misturae amygdalarum, ^viij. 
JNitrat. potassae, 9U* 
Tinct. digitalis, gtt. xv. 
Spiritus setheris nitrosi, gij. 

of which a tablespoonful was to be taken every second hour. 

There is one practical remark to be made on this and other similar 
cases. As soon as the symptoms of jaundice begin to decline, and bile 
makes its appearance in the stools, you should attend carefully to the state 
of the patient, and note any symptom which may occur of an anomalous 
character. Now, in this patient's case, we observed that a degree of 
restlessness was present, which terminated in a complete want of sleep. 
About the time when he began to manifest a degree of improvement, he 
became quite sleepless without any evident cause, and continued so for 
two or three nights ; and I have already stated in a former lecture that, 
no matter when this symptom occurs, whether in fever or towards the 
termination of some acute disease, it always requires your attention. I 
therefore immediately took proper steps to restore sleep ; and accordingly 
we find, on inquiring this morning, that he has rested well and feels much 
better. The man had been taking mercury, and his bowels were free ; 
but, not content with this, I gave him a purgative, consisting of infusion 
of senna with electuary of scammony. This he was directed to take early 
in the morning, so as to secure its operation before night ; and about nine 
or ten in the evening, after his bowels had been freely opened, he took a 
full opiate, which produced a long and refreshing sleep. 

Before I conclude, allow me again to communicate a few detached 
observations on the connection which existsbetween jaundice and some other 
diseases — as, for example, inflammation of the joints. It is now many years 
since Dr. Cheyne and I attended a gentleman in Lower Mount-street, who, 
in consequence of exposure to cold, was attacked with inflammation of the 
joints, accompanied by considerable general fever ; almost every joint 
was attacked in succession, and his sufferings were excessive. The 
disease bore the form I have so often described under the name of acute 
sweating arthritis — a form very obstinate and difficult to treat, and accom- 
panied after some time with great constitutional debility. When this 
gentleman had been about ten days confined to bed under treatment, he 
suddenly became jaundiced, and it was now evident that acute, but not 
violent, hepatitis was superadded to the original disease. 

In a day or two afterwards, a copious eruption of nettle-rash — urticaria 
— appeared over his body and extremities. Exactly the same diseases 
appeared, and in a similar order of succession, in a man treated in the 
Meath Hospital, in June, 1832 — an occurrence which at the time excited 
some interest among the students ; for when I observed that jaundice had 
supervened on arthritis, I mentioned to the class that it was not at all 



URTICARIA. 555 

unlikely that the jaundice would be soon attended by urticaria. I was 
induced at the time to make this prediction, as my mind was full of the 
subject, having been engaged, along with Mr. Porter, in attending a 
medical friend residing in Baggot-street, in whom jaundice was soon fol- 
lowed by urticaria. Since my attention has been drawn to the connection 
between these three diseases, I have seen and heard of several other 
instances in which they appeared thus associated together. A circumstance 
so remarkable deserves to be studied with more than ordinary interest. Let 
us, therefore, consider what facts are supplied by physiology and pathology 
capable of throwing some light upon this hitherto unobserved and uncul- 
tivated subject. In the first place, nothing has been longer recognised by 
physicians, as an established fact, than the intimate sympathy which exists, 
both in health and disease, between the digestive organs and the skin. 
Now, acute hepatitis always produces more or less derangement of the 
stomach and alimentary canal, and we may therefore consider its connec- 
tion with urticaria in the same way that we are in the habit of viewing the 
cases, so frequently observed, in which certain sorts of fish have produced 
serious symptoms of indigestion followed by nettle-rash. The association 
between these two diseases is rendered more remarkable by the fact, 
that, when fish taken as food exerts a poisonous effect on the system, it 
frequently produces not merely violent stomach and bowel complaint, but 
also inflammation of the joints and rheumatic pains. If I can establish 
this, you will allow that the connection between arthritis, disease of the 
digestive organs, and urticaria, can no longer be considered as fortuitous 
and depending on the accidental concurrence of causes having no deter- 
minate relation, but must be looked on as owing to and arising from the 
operation of some fixed law which regulates and originates this develop- 
ment of morbid actions in, if not a frequent, at least a uniform mode of 
succession. 

The Otaheitan eel (puhhe pirre rowte) produces, when eaten, a most 
copious scarlet eruption of the skin — most probably urticaria — and occa- 
sions sudden tumefaction of the abdomen, together with swelling of the 
extremities, hands, and feet, the pain felt in the limbs is so excruciating 
that the patient becomes quite frantic. I may remark here that this and 
many other species of fish which act as poisons on the system, give rise 
very speedily to paralysis of the extremities. You will find in the Edin- 
burgh Medical and Surgical Journal, vol. iv., p. 396, in an excellent 
review of Dr. Chisholm's work on the poison of fish, an account of the 
effects produced by eating the murcena conger, the following passage : 
11 In the course of the following night, they were all seized with violent 
griping and cholera, together with a peculiar sensation of the lower extre- 
mities, attended with violent convulsive twitches, faintings, &c. They 
all perceived a brassy taste in the mouth, and a rawness of the oesophagus, 
as if it had been excoriated. These symptoms continued to afflict the 
negroes for a fortnight, and then terminated in paralysis of the lower extre- 
mities. After suffering for several months, they recovered with difficulty." 

Are we not here forcibly reminded of what I said in a former lecture 
concerning the connection between enteric disease and paraplegia ? 

Werlhoff, as cited by my friend Dr. Autenrieth in a book* of extraor- 
dinary ability and research, gave a case where the gadus seglesinus asellus 
produced a violent affection of the stomach and bowels, together with 
* Ueber das Gift der Fische. Tubingen, 1833. 



556 CLINICAL MEDICINE. 

urticaria. Chisholm relates the same of the flesh of the dolphin. Urtica- 
ria, diarrhoea, dysentery, paraplegia, are said, by the same author, to be 
frequently observed in consequence of eating the flesh of the grey snapper. 
Forster relates a similar train of accidents produced by eating the sparus 
pargus (porgee). In short, I could bring forward citation after citation in 
proof of the truth above advanced ; but I have done, for enough has been 
already said to establish the point in question. 

Having established the fact that disease of the digestive organs is often 
intimately associated with urticaria, it remains to prove that a similar con- 
nection exists between hepatitis — the cause of the derangement in the diges- 
tive organs (in the case before us) — and arthritis. Every one has observed 
how frequently inflammation of the joints becomes in its course compli- 
cated with inflammatory affections of internal viscera. In general, those 
viscera whose component tissues are most similar to the articular are the 
organs affected. Hence the heart and pericardium are so often attacked 
in the course of rheumatic fevers. It sometimes happens, however, 
although less frequently, that the internal organ attacked has little analogy 
in point of tissue with the joints. Thus, in rheumatism and in gout, the 
stomach, the bowels, the lungs, or the liver, may become engaged ; and 
of these none, perhaps, so frequently as the liver. We need not be sur- 
prised at this, when we consider how intimately the digestive function is 
connected with arthritic inflammation, which is indeed generally preceded 
or accompanied by well-marked symptoms of hepatic and stomach com- 
plaints. Indeed, almost all medicines that afford relief in arthritis are 
attended with well-marked symptoms of their having acted upon the 
secretions of the alimentary canal and liver. Thus, colchicum seldom 
diminishes the pain and inflammation of the joints, until it produces 
copious bilious evacuations. 



LECTURE XLI. 

Case of secondary symptoms which made their appearance soon after a mercurial course ; 
method of treatment — Case of syphilitic eruption — Mouth suddenly affected by a small 
quantity of mercury — Effects of this on the progress of the cure — Earache preceded by rigors 
coming on during the course of fever; danger of ; treatment — External tenderness; value 
of, as a symptom in inflammation of brain, lungs, abdomen, &c, &c. — Vomiting considered 
as a symptom in fever; its treatment — Chronic rheumatism ; successful treatment of — Ob- 
stinate case of arthritis; cure of, by local applications — Observations on the effects of mer- 
cury applied locally — Case of syphilitic iritis; action of belladonna in. 

You have observed that w r e have two cases of syphilis under treatment — 
one in the female, the other in the male chronic ward. They possess no pe- 
culiar interest beyond the ordinary run of syphilitic affections, still they 
deserve a share of your attention; for it is on your experience of indivi- 
dual cases, much more than on the knowledge derived from books, that 
your treatment of this obscure and protean malady will depend. 

It is now more than a year since the female patient received the syphi- 
litic poison into her constitution. What the nature of the primary sore was 
we cannot ascertain, but, from the account she has given, it seems to have 
been true chancre. Some time after this occurred, she got sore throat, 
articular pains, and an eruption, for which she was treated in this hospital 



SECONDARY SYPHILIS. 557 

about ten months since, and dismissed apparently cured. The disease, 
however, returned in a few weeks, and she has been labouring under its 
effects up to the present moment. Three circumstances in this case demand 
our attention: first, the re-appearance of syphilis after a mercurial course 

-for she was mercurialized here soon after her first admission; secondly, 
she exhibits a degree of syphilitic cachexy, being rather pale and emacia- 
ted; and, thirdly, the slow progress which the disease has made in her 
system, being limited to a few blotches on the skin, some periostitic swel- 
ling of the bones of the leg, pains, and slight arthritis. 

In treating this case I intend to give mercury, so as to affect her sys- 
tem ; and, having accomplished this, I shall keep her under its influence 
for some time. I shall also, should it appear necessary, order her a free 
allowance of the decoction of sarsaparilla. Under this treatment you will 
find that the eruption will soon disappear, the periostitic pains and swel- 
ling be removed, and the constitution begin to improve. She has been 
ordered three grains of blue pill, and half a grain of calomel, three times 
a-day — a quantity which you will generally find sufficient to bring on mer- 
curial action in females. I have no doubt but that the disease will, in this 
case, yield to mercury in a very short time, and that her health will be 
completely restored. The failure of mercury in producing a permanent 
cure, on a former occasion, is no argument against its employment here; 
if there were no syphilitic taint in question, I do not know any remedy by 
which the cutaneous affection and the periostitis could be more effectually 
relieved. On another occasion I shall speak more at large upon this im- 
portant subject, and shall bring forward facts in proof of the assertion, that 
mercury may fail to eradicate the effects of the venereal poison at a certain 
period of the disease, and may nevertheless be capable of curing the dis- 
ease effectually at a future time. This may appear paradoxical, but it is 
not the less true. 

The other patient, John Kelly, presents an eruption of red scaly blotches, 
extensively diffused over the trunk and extremities, and closely resem- 
bling psoriasis. This man, like many others, denies the occurrence of a 
recent syphilitic taint, and gravely states that it is some years since he ex- 
posed himself to infection. Instances of this kind are to be met with every 
day ; patients will not tell the truth about these matters, and false state- 
ments tend to throw a darker shadow over a disease in itself sufficiently 
obscure. However, in this case, the poison seems to have confined its 
effects to the cutaneous surface; there is no affection of the throat, perios- 
teum, or joints. The eruption covers almost every portion of his body; 
it made its appearance two months before admission, and was preceded 
by feverish symptoms and pains in the larger articulations. 

In undertaking the treatment of this case, there is one practical point to 
be held in view. The man's general health is good, his strength undi- 
minished, and his circulation active. I therefore ordered him to be blooded, 
and have kept him for eight or nine days on antimonials and low diet. 
By preparing him in this way, I knew that the mercury which I intended 
to give him would act more rapidly on his system; and such was the case 

-for on the second day after he commenced using it his mouth became 
affected. But here a difficulty arose, which, in cases of this description, 
is apt to embarrass our treatment ; the mercurial influence appeared much 
sooner than I expected or wished. He had been ordered three grains of 
blue pill, and half a grain of calomel, three times a-day; and on the second 



5£8 CLINICAL MEDICINE. 

day, before he had taken six pills, salivation commenced. Now, in all 
cases where mercury affects the mouth sooner than you desire, and as it 
were in spite of you, it will not do as much good as where its action pro- 
ceeds regularly and in accordance with your purpose. It is a general rule, 
that most benefit is to be expected from mercury where its action is regu- 
larly progressive, or where the quantity taken is in proportion to the effect 
produced on the system. Hence we look upon it as an unfavourable oc- 
currence, when a small quantity of mercury occasions sudden and copious 
salivation; such an event deranges our calculations, and tends to embar- 
rass our practice. Now, in this case the patient, after taking five pills, 
became salivated on the second day. We found we had been going on 
too fast; it was necessary therefore to pause, but not desist. We accord- 
ingly reduced the quantity of mercury to three grains of blue pill, and half 
a grain of calomel, to be taken every second night. By these means we 
kept up a slight discharge of saliva, and the man's symptoms began to 
improve. The eruption is now disappearing rapidly, and it is to this point 
I wish to call your attention. What are the marks which indicate the 
subsidence of an eruption of this kind, and by what criterion are you ena- 
bled to judge of the progress of the cure? W T hen the parts are about to 
return to their healthy condition, three circumstances occur : first, the vivid 
red or copper colour of the eruption begins to fade ; secondly, the heat of 
the affected parts becomes reduced ; thirdly, the excessive secretion of 
morbid cuticle is arrested, and the quantity of minute scales covering the 
blotches diminished. In such cases, the affected parts of the skin are 
highly vascular, and the secretion of cuticle is morbidly excessive in quan- 
tity; hence the continued desquamation from the surface of the blotches. 
You should, therefore, attend not merely to the colour of the eruption, but 
also to the quantity of minute scales on each blotch, when you wish to 
ascertain whether an eruption is fading or not. You can judge of this by 
your eye, or you can tell it by passing your finger over the diseased sur- 
faces. The fading of the colour of the eruption, the decrease of the ele- 
vation and roughness in the blotches, and the gradual disappearance of the 
minute scales — these are the circumstances by which you can ascertain the 
subsidence of a syphilitic eruption. As the cure progresses, you find the 
parts assuming a more natural appearance: the same quantity of morbid 
cuticle is no longer thrown out by the affected spots of corium ; the blotches 
become smooth and lose their elevation, and, finally, the red colour of the 
skin disappears. Of all the symptoms, discoloration of skin is the last to 
recede, and it generally happens that enough has been done in the way of 
treatment long before the skin resumes its natural complexion. If you 
were to continue the administration of mercury until the natural colour 
returned, you would very often push it to a useless and even dangerous 
extent. In such cases, a faded brownish or dirty tinge remains long after 
the re-establishment of healthy action. 

There is a case in the female fever ward which requires a passing 
observation. A young woman, previously in the enjoyment of good 
health, was seized with symptoms of fever after exposure to cold ; she 
got rigors, followed by headache, hot skin, thirst, nausea, and accelera- 
tion of pulse. It is unnecessary for me to detail the symptoms which 
attended her illness during the past week ; I shall content myself with 
pointing out the symptoms which particularly attracted my attention to 
her ca>e on Saturday morning. At that time her fever had increased ; 



EAR-ACHE PRECEDED BY RIGORS IN FEVER. 559 

she complained of severe headache and restlessness ; had foul tongue, 
thirst, and symptoms of gastro-intestinal irritation. Such matters, how- 
ever, demand no very particular consideration ; what chiefly fixed my 
attention was the occurrence of slight and transient rigors during my exa- 
mination : I observed her shuddering three or four times in the space of 
a few minutes. On questioning her respecting these brief rigors, she 
informed me that they had occurred with more or less frequency for the 
last three days. Now, whenever you meet with a symptom of this de- 
scription in fever, be on your guard ; watch the case with anxious, unre- 
mitting attention, and never omit making a careful examination. It is in 
this way that one of the worst complications of fever — treacherous and 
fatal disease of the brain — very often commences. On examining this 
girl, we found that she had not only headache, but also acute pain refer- 
red to the left ear, the external meatus of which was observed to be hot 
and tender to the touch. In addition to this we were informed by the 
nurse that she had been seized with a sudden fit of vomiting shortly after 
we left the ward on the day before. Here was an array of threatening 
symptoms calculated to awaken attention in any, even the most heedless 
observer. A patient, after exposure to cold, is attacked with symptoms 
of fever ; she has headache and restlessness ; she then begins to complain 
of acute pain in the ear, darting inwardly towards the brain ; and, finally, 
is seized with sudden vomiting. Under these circumstances, it is not dif- 
ficult to form a diagnosis, and there can be little doubt but that the phe- 
nomena here present were indicative of incipient inflammation of the 
membranes of the brain. Tt is not easy to say whether in such cases the 
inflammatory affection of the membranes precedes the external otitis, or 
whether the inflammation commences in the external ear and spreads 
inwards, though I am inclined to adopt the latter supposition, and the 
circumstance of the fever and earache arising from cold seems to give an 
additional degree of probability to this view of the question. Be this as 
it may, there could be no doubt but that this girl was, on Saturday, 
labouring under incipient inflammation of the membranes of the brain, as 
denoted by headache, rigors, acute pain in the ear, and vomiting. 

Here let me observe, gentlemen, that in cases of this description, I look 
on the occurrence of external tenderness, not merely as an indication of 
internal disease, but also as a favourable symptom. I have remarked that 
in all cases where this happens, the physician becomes more speedily and 
sensibly aware of the existence of internal disease, and the remedial means 
employed act with a more decidedly beneficial effect. I would prefer 
having to deal with an inflammatory affection of the brain or bowels, ac- 
companied by external tenderness, and would feel much more certain as 
to the result, than if this symptom were but faintly marked, or totally 
absent. This observation is founded on experience. 

In treating this case, you have seen that I have ordered relays of 
leeches to be applied in the vicinity of the affected ear until the earache 
has ceased. I have long followed this practice of applying a number of 
leeches in succession for the relief of local inflammation, and I c*n state 
with confidence that the result has been, in the majority of cases, highly 
satisfactory. Some prefer the application of a great many leeches at 
once ; but my experience speaks strongly in favour of the practice of 
applying a small number, repeated at short intervals, until the violence of 
the local inflammation is subdued. Relays of six or eight leeches will 



560 CLINICAL MEDICINE. 

suffice in the majority of cases of pectoral, cerebral or abdominal inflam- 
mation. In some, however, when the attack is violent, fifteen or twenty 
must be applied at once ; each succeeding relay may consist of a smaller 
number than that which preceded it. In this manner I have maintained 
a constant oozing of blood from the integuments over an inflamed organ 
for twenty-four, or even thirty-six hours. In addition to this, I determined 
to bring her system rapidly under the influence of mercury, and, with this 
intent, administered calomel to the amount of a scruple in the twenty-four 
hours. These means have acted favourably, and she feels much better 
to-day. (This patient perfectly recovered.) 

Allow me to make one observation more which this case suggests. 
This young woman, you recollect, had, on her admission, some epigastric 
tenderness, w T hich we removed by leeching, and she remained free from 
any symptoms of gastric irritation until last Saturday, when she got a sud- 
den attack of vomiting. Now, in all feverish, complaints, where, during 
the course of the disease, the stomach becomes irritable without any obvious 
cause, and where vomiting occurs without any epigastric tenderness, you 
may expect congestion, or incipient inflammation of the brain or its mem- 
branes. If called to a case of scarlatina, where there is severe vomiting, 
and perhaps diarrhoea, unaccompanied by thirst or epigastric tenderness, 
what should your practice be ? Are you to direct your attention to the 
alimentary canal, and endeavour to arrest these symptoms? No. The 
vomiting here depends on active congestion of the head, and such cases 
are very apt to end in coma, convulsions, or death, from disease of the 
brain. You are all aware, that in cases of injuries of the head, followed 
by congestion of the brain, vomiting is one of the most prominent symp- 
toms. The same thing occurs in febrile affections, attended with deter- 
mination to the head. You are not to conclude that a fever is gastric, 
because it commences with nausea and vomiting: this is a serious, and 
very often a fatal mistake ; yet I am sorry to say it has been committed 
by many practitioners, and I have been guilty of it myself. In such 
cases, you should not waste time in attempting to relieve gastric irrita- 
tion by cold drinks, and leeches to the epigastrium, or to check diarrhoea 
by chalk-mixture and opiates ; you should direct your attention at once 
to the seat and origin of the mischief, and employ prompt and effectual 
means to relieve the cerebral congestion. Where the disease sets in with 
severe vomiting, unaccompanied by distinct evidences of gastric inflam- 
mation, whether it be common fever, or scarlatina, or measles, or small- 
pox, I commence the treatment by applying leeches to the head, convinced 
that in this way I shall be most likely to prevent an approaching danger- 
ous congestion of the brain. I am anxious to impress this observation on 
your minds, because I am fully sensible of its importance, and feel certain 
that you will derive much advantage from bearing it in recollection dur- 
ing the course of your future practice. 

The next affection to which I shall draw your attention is chronic rheu- 
matism, of which we have a well-marked instance in the man who lies in 
the chronic ward immediately under the window. He complains of pain, 
weakness, and numbness of the lower extremities, for which he used the 
decoction of sarsaparilla and minute doses of corrosive sublimate, for a 
fortnight, without any obvious improvement in his symptoms. His com- 
plaint is of considerable duration, it being now fifteen weeks since he was 
first attacked. This, I need not tell you, is a very unpromising feature 



CHRONIC RHEUMATISM. 561 

in his case. When rheumatism has continued for three or four months, 
it becomes a very intractable disease ; indeed, there is scarcely any atten- 
tion which tasks the ingenuity, and tries the patience, of a medical man 
more than chronic rheumatism. In this case, however, we have been so 
fortunate as to hit on a remedy suited to the complaint ; the man has been 
rapidly improving within the last fortnight, and is now nearly well. You 
will recollect that, when I undertook the treatment of this ca^e, the patient 
was free from fever, his general health but little impaired, his pulse tran- 
quil, his appetite good, no remarkable tenderness or redness of the joints 
— in fact, nothing to indicate the existence of acute local inflammation ; 
consequently, it would have been useless to have recourse to leeches or 
blood-letting, or to administer antimonials, nitre, or colchicum. In such 
cases as this a different line of practice must be followed ; you must have 
recourse to stimulant diaphoretics — remedies which will increase the secre- 
tion from the skin, at the same time that they exercise a stimulating action 
on the nervous and capillary systems. Accordingly we prescribed for this 
man the following electuary, of which he was to take a teaspoonful three 
times a-day : — Powdered bark ^j., powdered guaiacum ^j., cream of 
tartar §j., flower of sulphur ^ss., powdered ginger ^j. ; to be made into 
an electuary with the common syrup used in hospitals. The guaiacum 
not only acts on the nerves, tending to remove chronic pains, but also 
acts on the skin ; you will find these, and other properties possessed by 
it, detailed at large in your works on Materia Medic a. Whether given 
in the form of powder or tincture, it often proves an extremely useful re- 
medy in cases of chronic rheumatism, where no symptoms of active local 
inflammation or general lever exist ; where either of these are present it 
is inadmissible. Ginger has also a stimulant effect, although its action is 
much more limited. It is a favourite domestic remedy, and is very fre- 
quently prescribed by our rival candidates for therapeutic celebrity — old 
ladies — in cases of chronic, or, as they term it, cold rheumatism ; and I 
must confess that I have seen some benefit derived from their specific — 
ginger tea. With these we combined sulphur, which exerts a peculiar 
stimulant operation on the skin and alimentary canal. Sulphur is an ex- 
tremely active remedy, and singularly penetrating in its nature, finding 
its way into many of the secretions and most of the tissues of the body. 
You will find it in the urine in the form of sulphates, and it is exhaled 
from the skin and mucous membrane of the bowels in the form of sulphu- 
retted hydrogen. Having said so much respecting sulphur, you will per- 
haps inquire why I prescribed the bark r It is not easy to give a satis- 
factory explanation of this : but we know, from experience, that in cases 
of rheumatism, after fever and local intiammation are removed, bark and 
other tonics have been found extremely valuable. The cream of tartar is 
given with the view of tempering the other stimulant remedies, it being 
known to possess cooling and aperient properties. The whole form a 
combination which is similar in its composition to a well-known popular 
remedy for rheumatism — the Chelsea Pensioner. 

Having thus explained the general tendency of these medicines, and 
mentioned that they are to be made up into an electuary, it only remains 
to speak of the effect produced, and the dose or quantity to be given. I 
have stated that the ordinary dose is a teaspoonful three times a-day ; 
this, however, will be too much for some, and too little for others. The 
object in every case should be to keep up a mild but steady action on the 
37 



562 CLINICAL MEDICINE. 

bowels, and to procure a full alvine discharge at least once a-day. If the 
dose mentioned already does not answer this purpose, it must be increased ; 
if the bowels are too free, it must be diminished. You should never 
omit making regular inquiries after the state of the bowels, while the 
patient is using this electuary ; for, if these matters are neglected, the 
patient will not obtain the full benefit to be derived from it. Besides 
opening the bowels this electuary acts on the skin, and frequently causes 
a rapid disappearance of the disease. I need not say that, in addition to 
this, I ordered warm baths ; they coincide in effect with the electuary, 
acting on the skin, and tending to relieve the rheumatic pains. 

There is another very remarkable case bearing some affinity to the pre- 
ceding, on which it may be necessary to offer a few remarks ; I allude to 
the patient with sweating arthritis, to whom I drew your attention this 
morning. This poor man, who is somewhat advanced in life, has been 
labouring for several months under inflammation of the joints of a rheu- 
matic character, manifesting itself by pain, stiffness, swelling, and pro- 
bably some slight effusion into the synovial membranes. These symptoms 
were accompanied by profuse and constant perspirations, with a tendency 
to diarrhoea — circumstances which caused a manifest deterioration of his 
health and strength ; he became pale, cachectic, and emaciated. His 
case had been very tedious and intractable ; he had been a long time in 
the hospital, and had used all the most appropriate remedies, but without 
any appreciable improvement ; his joints remained stiff, painful, and 
almost useless ; he was greatly reduced in strength, and entirely con- 
fined to his bed. In addition to this, his pulse continued unreduced in 
frequency, and this is always a bad sign ; cases of rheumatic arthritis, 
attended by prolonged excitement of the circulation and copious sweat- 
ing, are generally found to exhibit an intractable chronicity, and too often 
terminate in rendering the unfortunate patient a cripple for life. 

Now in this case many remedies had been tried without effect, and 
the state of the man's constitution, combined with the circumstance of his 
having a tendency to bowel complaint, contributed to reduce still further 
the scanty list of our remedial agents. Alterative remedies, to affect the 
general system, were almost entirely out of the question, and a vast 
number of local applications had proved unsuccessful. It occurred to me 
here, that some benefit might be derived from mercurial ointment, gently 
rubbed over the affected parts, assisting its action by the use of rollers 
applied around the joints. Fortunately, the experiment proved successful ; 
in the course of a week or ten days, the swelling diminished considerably, 
the pain is nearly gone, and the power of motion is returning. His mouth 
has become affected, but the relief experienced appears to be proportioned, 
not to the influence of mercury on the general system, but to its effect on 
each individual joint. As a proof of this, I may state that the man has 
been mercurialized before, but without any favourable result. 

Here, gentlemen, is an important point for consideration. A patient 
labours under a certain number of local inflammations, for which mercury 
is given internally, so as to affect the mouth, but without any manifest 
improvement of symptoms ; we afterwards try the same remedy in another 
form ; we apply it locally, in the shape of ointment, rubbed into the skin 
over the diseased parts, and we succeed in giving relief. This is a fact 
deserving of attention. You will perhaps ask me to explain this — I cannot 
do it ; but I can bring forward many other analogous examples. If you 



GREAT UTILITY OF LOCAL APPLICATION OF MERCURY. 563 

refer to the late Mr. M'Dowel's valuable paper on Erysipelas, published in 
an early number of the Dublin Medical Journal, you will find that many 
cases of this affection derived great benefit from the use of mercurial 
ointment; in fact, much more than they could by giving mercury inter- 
nally. In the next place, I have met with many cases of enteritis and 
peritonitis, where the disease continued after the system became affected 
by mercury ; and I have observed that these cases yielded rapidly to 
blistering the abdomen, and dressing the raw surfaces with mercurial 
ointment. Sir H. Marsh and I attended a young gentleman lately, who 
had low fever, accompanied by a quick but feeble pulse, and great rest- 
lessness. About the tenth day, his belly became tender and exquisitely 
painful ; he had thirst, diarrhoea, and other symptoms of enteric and peri- 
toneal inflammation. Before his illness, he had been of rather delicate 
habit, and had further impaired his health by close study. He was there- 
fore unfit for depletion, and of this we were convinced by the debility 
which followed the application of a few leeches. Under these circum- 
stances, we ordered a large blister to be applied to the abdomen, and the 
vesicated surface to be dressed with mercurial ointment. This proved 
eminently successful ; the peritonitis, enteric irritation, and fever, soon 
disappeared, and the young gentleman recovered completely. The same 
thing is seen in many cases of pleuritis ; the constitutional effect of mer- 
cury will fail in removing the affection of the pleura until it is applied 
locally. I might also refer to instances of common inflammation of the 
testicle, in which mercurial ointment, smeared over the part, has been 
found decidedly beneficial. It is unnecessary for me, however, to mul- 
tiply examples ; what 1 have stated give ample proof of the utility of 
mercury applied locally. When I was a student, it was the fashion to 
scout the doctrine that any distinct effect could be produced by the local 
application of mercury ; our teachers laid it down as an axiom, that, to 
produce any sensible effect, it was necessary that it should first enter the 
system through the lymphatics. Thus, when you rub mercurial ointment 
over the liver to remove hepatic derangement, they said, before it could 
exert any influence on the liver it had to pass along the thoracic duct, 
become mixed with the circulation, and manifest its peculiar action on 
the whole economy. Hence, in a case of hepatitis or testitis, it was 
deemed useless to apply mercurial ointment over the liver or testicle, 
since it had, as they expressed it, to go its round through the whole 
system, before it could affect either of these organs. This reasoning has 
an appearance of plausibility, but it is contradicted by facts. Numerous 
examples might be cited to prove that the greatest advantage may be 
derived from the local application of mercury, independent of any effect 
produced by it on the general system. How often do we see an incipient 
bubo dispersed by mercurial frictions, before any constitutional effects 
occur? How frequently do we see laryngeal and hepatic inflammation 
relieved by the use of mercurial ointment without salivation ? Do the 
beneficial effects, which we so often observe from the emplastrum ammo- 
niaci cum hydrargyro, depend necessarily upon the mouth being affected ? 
Is the relief which follows the use of mercurial ointment in erysipelas 
or testitis, unattainable unless preceded by mercurial action in the whole 
system? Indeed, any person who reviews this subject dispassion- 
ately, will see that the doctrine of a preliminary constitutional affection 
being absolutely necessary, in order to obtain the specific action of mer- 



564 CLINICAL MEDICINE. 

cury on any particular organ, is wholly untenable ; while, on the other 
hand, there is a host of evidence to prove that, locally applied, it pro- 
duces a primary and distinct effect, totally independent of its action on 
the general economy. 

The last case to which I shall direct your attention, is one of syphilitic 
iritis. A young man has been admitted this morning, presenting symp- 
toms of secondary syphilis in a well-marked form, but simple and uncom- 
plicated by any previous treatment. He took no medicine for the primary 
or secondary symptoms, except two pills, which he got at the dispensary 
about two months ago, and which were not followed by any sensible 
effect. The secondary symptoms came on with pains and feverishness, 
and are at present extensively diffused over his body in the form of ele- 
vated blotches, of a character intermediate between the papular and squa- 
mous. About four or five days back, he was advised to take a warm 
bath for his pains, but having to walk a considerable distance afterwards, 
the day also happening to be chilly and sharp, he got cold in returning 
home, and soon after experienced pain in the left eye, with lachrymation, 
and diminution of the power of vision. Had he been exposed in the same 
way while in health, he would probably get slight conjunctivitis, or sore 
throat, or bronchitis ; but the case was altogether different with a man 
labouring under a constitutional affection, having a tendency to manifest 
itself in almost every tissue of the body, and prepared to modify every 
form of inflammation to which accident might give rise. Again, if the 
man's constitution was in a sound state, his feverish cold, or conjunctivitis, 
or sore throat, could be removed by very simple means, such as bathing 
-the feet, taking a little warm whey on going to bed, and some opening 
medicine the next morning. But here the state of the constitution occa- 
sions the substitution of syphilitic iritis for simple conjunctival inflamma- 
tion, and demands a peculiar plan of treatment. You are all aware, that 
persons w T ho have taken mercury for syphilis, without being entirely 
cured, are very liable to get iritis on slight exposures. Some persons 
attribute this entirely to the mercury ; but mercury, in such cases, merely 
acts by rendering the patient more liable to cold, so that when iritis occurs 
in a patient who has been under a mercurial course, it is not in conse- 
quence of the direct operation of mercury, but by its increasing his lia- 
bility to be affected by impression from cold. For the same reason, the 
circumstance of his having taken mercury before, is not, as some persons 
maintain, any argument against his using it a second time. 

On examining this man, we found that he had some pain referred to 
the eyebrow ; the eye is also more vascular than natural, and presents 
that appearance which is so characteristic of iritis ; there is some alteration 
in the colour of the iris along its free margin, but no irregularity of pupil. 
Along with these symptoms, there is dimness of vision, and objects ap- 
pear as if seen through a veil. This arises not from any opacity of the 
cornea, or opalescence of the aqueous or vitreous humours, but from 
inflammation affecting the iris, ciliary zone, and, probably, the coats of 
the retina. In such cases, where the inflammation spreads from the iris to 
the ciliary zone, it would appear that the ciliary nerves and retina partake 
in the mischief, for vision becomes affected before we can discover any 
appearance of derangement in the optical instrument. The peculiar ap- 
pearance of the eye in this man, the change of colour in the free margin 
of the iris, and the diminution of the power of vision co-existing with an 



SYPHILITIC IRITIS. 565 

eruption of the skin, point out the nature of the disease, and show that the 
affection of the eye, though proceeding from a common cold, has been 
modified by the syphilitic taint in the constitution. 

We next come to consider the plan of treatment to be pursued. In order 
to prepare his system for mercury, I have ordered him to be blooded, 
purged, and put on the use of antimonials for two or three days. Vene- 
section, purging, and tartar emetic, may be of some use in relieving or 
arresting the symptoms of iritis, but I do not place any great reliance on 
them for removing the disease; I merely employ them as auxiliaries, de- 
pending on mercury for the cure. Here it may be necessary to observe, 
that there is considerable variety in cases of iritis. Some are extremely 
mild ; there is no palpable sign of acute inflammation present, and the chief 
symptom is diminution of the power of vision. Such attacks are sometimes 
not perceived by the patient until some accident informs him that the sight 
of one eye is nearly gone. In other cases, after reaching a certain point, 
it begins to decline, and frequently terminates spontaneously. Others pre- 
sent symptoms of a more decided character, but still are free from danger. 
Every attack, however, where the inflammation is at all of an intense cha- 
racter, will go on to destroy vision, unless met by prompt and efficacious 
treatment. In this man's case the symptoms are not very acute, and hence 
there is no necessity for having recourse to mercury at once; the disease 
might certainly terminate in disorganization of the eye, but it would be 
some weeks before this would be accomplished. On the other hand, there 
are cases which, if neglected, would destroy vision irremediably in the space 
of three or four days. Such cases require extremely prompt and ener- 
getic measures. But where iritis is not of a violent kind, you need not 
depart from the plan of treatment you would have laid down for the cure 
of syphilitic affections where no iritis existed. Here you bleed, purge, 
give antimonials and mercury, and you find that the syphilitic eruption 
and iritis disappear together. But where the symptoms of iritis are so 
severe as to threaten rapid disorganization of the eye, you disregard the 
syphilitic affection, and direct your entire attention to the preservation of 
the eye. Here you bleed, leech, apply belladonna to the eye, and give 
calomel, in doses of ten grains or a scruple, every third or fourth hour, 
so as to bring the system as rapidly as possible under the influence of 
mercury. 

With respect to belladonna, I believe you are all aware of its value in 
iritis. Some think that its action is merely mechanical, that it dilates the 
pupil and no more; but I am firmly convinced that its influence is not 
limited to mere dilatation of the pupil. I believe that, it acts on the vita- 
lity of the eye, and that when employed externally or internally, it pos- 
sesses the property of diminishing the irritability of that organ, and thus 
tends indirectly to remove local inflammation. In scrofulous ophthalmia, 
where the eye is exquisitely sensible, where the slightest exposure to light 
causes intense pain and copious lachrymation, one of the best remedies I 
am acquainted with is belladonna, given internally. Thus you perceive 
that belladonna has not only a mechanical action, producing dilatation of 
the pupil, and tending to prevent adhesions, but also, by its influence on 
the retina and ciliary nerves, diminishes the irritability of the eye, and aids 
materially in effecting the removal of local inflammation. 

I have spoken on a former occasion of the utility of mercury in certain 
cases of rheumatic fever, where the inflammation of the joints will not yield 



566 CLINICAL MEDICINE. 

to other means: I have now to add, that for the last seven or eight years 
the hydriodate of potash has been found to be a most useful adjunct to 
mercury, and well calculated for following up and completing the benefi- 
cial effects produced by that remedy. In fact, in treating arthritic or rheu- 
matic fever, when I have reduced the violence of the fever and of the in- 
flammatory affection of the joints by means of bleeding and leeching, fol- 
lowed by tartar emetic or nitre, or both combined ; or when after the anti- 
phlogistic treatment, both local and general, I have produced a marked 
alleviation of the patient's sufferings, either by the use of colchicum or by 
the use of mercury combined with opiates — then, I say, we can employ 
the hydriodate of potash with the greatest possible advantage, as it quickly 
dissipates the remaining pain and swelling of the joints, and contributes 
powerfully to bring the disease to a speedy termination, while at the same 
time it greatly diminishes the danger of a relapse. I have experienced 
much comfort and feel much confidence in the treatment of rheumatic fever 
since I adopted this practice ; and it now never happens to me to meet 
with cases which, in spite of all my efforts, become chronic, and confine 
the unfortunate sufferers to bed for months. You have observed, that in 
most cases of acute rheumatism affecting the joints, no matter what mode 
of treatment I adopt in the commencement and during the acme of the dis- 
ease, I generally complete the cure with the hydriodate of potash, begin- 
ning with doses often grains, which are quickly augmented to twenty or 
thirty grains, three times a-day. It is generally given in decoction of 
sarsaparilla, to which some preparation of morphia forms a useful addi- 
tion. 

Iodine and hydriodate of potash exert a vary powerful influence over 
scrofulous inflammation: but their influence, as has been proved by recent 
experience, extends likewise to inflammations connected with olher states 
of the constitution, and they are frequently exhibited now with the best 
effects in certain varieties of syphilis, pseudo-syphilis, gout, mercurial 
cachexy, and rheumatism. The power of iodine in moderating mercurial 
salivation and the severe ulceration of the mouth which frequently accom- 
panies it, has been asserted by some and denied by others. Be this as it 
may, it certainly is an excellent adjuvant to our usual means for diminish- 
ing the pain and inflammation which attend periostitic affections, and many 
of the troublesome sequelae of syphilis. I may observe also, that the hy- 
driodate of potash has been found to prove a most valuable auxiliary in 
the treatment of chronic anasarca and the ascites that follows scarlatina. 
In another place I have spoken more fully of the utility of hydriodate of 
potash in arthritic rheumatism, lumbago, and sciatica; and Dr. Osbrey has 
likewise directed the attention of the profession to its powers in these af- 
fections, in an extremely valuable practical paper on the combinations of 
iodine, published in a late number of the Dublin Medical Journal, to which 
I feel pleasure in referring the reader. 

I have been told likewise by some excellent practitioners, that they 
have derived much advantage from the ioduret of iron in rheumatic affec- 
tions of the joints, after the acute stage has subsided. My own experience 
of the effects of this remedy is too limited to allow me to express any 
opinion on its merits. 

Having spoken of mercurial salivation, it occurs to me this moment, 
that the remarkable fact of the difficulty of salivating infants and very old 
persons must depend, in some measure, on the undeveloped state of the 



CLEAR SOUND OF SOLIDIFIED LUNG. 567 

parotid glands of the former, and their shrunken and atrophied condition 
in the latter. The apparatus connected with the insalivation of the food 
is comparatively but little required before the teeth appear in infancy, or 
after they have fallen in advanced age. 

I wish now to make a few observations on the use of decoction of sar- 
saparilla and nitric acid in certain cases of chronic cough. The utility of 
this combination has been long recognised in cachectic states of the sys- 
tem and affections of the skin, whether syphilitic or mercurial ; and it has 
also proved itself very efficacious in various species of sore throat, chronic 
pains, and other textural derangements of a slow and tedious character. 
The marked effects which the decoction of sarsaparilla and nitric acid 
produce in these diseases of the general habit, skin, and raucous mem- 
brane of the throat, led me to infer, that the same combination might be 
employed with advantage in cases of chronic cough, attended with red- 
ness and relaxation of the mucous membrane of the fauces, elongation of 
the uvula, and some degree of general debility. I have observed that 
such cases are almost invariably accompanied by more or less derangement 
of the digestive organs and an irritable state of the general system ; and 
from their analogy to other states of the constitution, in which nitric acid 
and sarsaparilla have proved extremely beneficial, I was induced to give 
this combination a trial ; and I can now state, that it has not disappointed 
my expectations. Decoction of sarsaparilla, given in doses of a pint daily, 
with a drachm or more of nitric acid, has proved a most useful and valua- 
ble remedy in the treatment of cases of this description. It is scarcely 
necessary to observe, that in addition to the use of this remedy, change of 
air, moderate exercise and recreation, and a nutritious but not heating 
diet, are required. In some of these cases it will be also necessary to 
apply lotions of the nitrate of silver or sulphate of copper to the fauces 
and tonsils ; and where the uvula is greatly relaxed, it will require to be 
frequently touched with the nitrate of silver, or even to be shortened by 
an operation. Guided by the same principles, I have frequently exhibited 
decoction of sarsaparilla with nitric acid in cases of persons of a reduced 
and relaxed habit, who are troubled with a slight but frequently-recurring 
cough or hem, and the expectoration of a few bronchial sputa, occasion- 
ally mixed with blood, which appears to come, not from the lungs, but 
from the eroded mucous membrane at the top of the pharynx and larynx. 
In such cases I have observed, that the cough and expectoration took 
place chiefly in the morning after awaking, and in some had continued 
for weeks without any dyspnoea, pain in the chest, or fever. I may also 
remark, that the same combination may be often given with advantage to 
patients whose mouths have been recently made sore by mercury admi- 
nistered for the cure of bronchitis or pneumonia, and will occasionally be 
found useful in removing the still lingering remnant of pulmonary disease, 
at a time when mercury could not be pushed farther with safety. 

Speaking of pulmonary affections leads me to notice a collateral subject 
of very great importance : I allude to percussion as a means of arriving 
at a true diagnosis in cases where solidification of the lung has taken place. 
It is generally believed, that in cases where the actual quantity of air in 
the lungs is morbidly increased or diminished, percussion furnishes us 
with means of information adapted to every variety of case, and capable 
of unlimited application. This, however, is not the fact. It is true that 
when percussion furnishes positive evidence of increased pulmonary soli- 



568 CLINICAL MEDICINE. 

dity, we may be pretty sure that solidification exists ; but such evidence 
is not furnished by percussion in every case of the kind indiscriminately ; 
for it now and then happens, that percussion elicits a very clear sound 
from the parietes of the chest, corresponding to considerable solidification 
of the lungs within. Of this I have now witnessed several instances. 
You will ask, how then are to explain this apparent contradiction between 
the results afforded by percussion ? This is a question of much import- 
ance, and I hope the solution which I am about to offer will' be found 
adequate and satisfactory. 

An old man named Foy died lately at Sir P. Dun's Hospital, of hepa- 
tization of the inferior lobe of the right lung, with numerous tubercular 
depositions in the upper lobes of both lungs. During his illness, I pointed 
out the existence of extensive hepatization of the lower lobe of the right 
lung, in which perfect and decided dulness marked out accurately the 
space occupied internally by the solidified pulmonary tissue. But ante- 
riorly and above, the parietes of the chest returned a clear sound on per- 
cussion, nor could a vestige of dulness be anywhere detected. Yet the 
whole of the upper lobes of this patient's lungs were occupied to such an 
extent by crude tubercles, that no portion of the upper lobes could be 
selected, equal to half the size of a fist, which would not sink in water. 
This was owing to tubercular matter, which occupied the pulmonary tis- 
sue in detached infiltrated masses, or in single crude tubercles. How, 
then, did it happen that such extensive solidification of the upper lobes 
existed without any corresponding dulness on percussion ? A careful 
examination of the pathological condition of these lobes satisfactorily ex- 
plained the anomaly. On accurate inspection, we found that although 
the solidified masses of the pulmonary tissue were extremely numerous, 
and predominated over the parts which still retained their natural vesicu- 
lar texture, so that an extensive portion of the upper lobes seemed to be 
quite solid, yet the solidified portions were insulated and divided from 
each other, throughout the interior of the lobe, by intervening laminae of 
healthy pulmonary tissue, and on their surface were, for the most part, 
covered by a stratum of healthy vesicular lung, from a quarter to half an 
inch in thickness. Indeed, although the solidified masses (to use a geo- 
logical expression) sometimes cropped up, and came to the surface, yet 
this was comparatively a rare occurrence ; and by far the greater portion 
of that surface was composed of a thin stratum of pervious vesicular tis- 
sue. To this was owing the clear sound elicited by percussion. 

You will recollect, therefore, that in certain (I will admit rare) cases of 
tubercular deposition in the lungs, the tubercular development may have 
proceeded to the extent of rendering the greater portion of the upper lobes 
impervious to the air, and may have solidified those lobes considerably, 
and yet the solidified portions may be so divided from each other by laminae 
of healthy lung, and may be so covered by a stratum of vesicular tissue, 
that the general result of percussion is to elicit a clear sound over the 
whole of the parietes of the chest corresponding to the affected lobes. 



CHRONIC DIARRH(EA. 569 



LECTURE XLII. 

Persesquinitrate of iron in chronic diarrhoea — Newly observed affection of the thyroid eland in 
females — Its connection with palpitation ; with fits of hysteria — Erysipelas — Remarks on 
the formation of acidity of the stomach in indigestion — Psoria.-is — Treatment by arsenic. 

Having lately used, with very considerable success, a preparation intro- 
duced by Dr. Christison, namely, the persesquinitrate of iron, I shall make 
a few observations here on its properties and use. 

The combination of iron with nitric acid forms a remedy possessing 
tonic, and, at the same time, astringent powers, and hence peculiarly well 
adapted for the treatment of certain forms of chronic diarrhoea and dysen- 
tery. You will be consulted by females of a delicate and weakly habit, 
who frequently exhibit symptoms of nervous derangement, such as palpi- 
tations, sleeplessness, and headache, who are easily excited or alarmed, 
have a tendency to emaciation and paleness, and have little or no appe- 
tite. Combined with these general symptoms, you find that they have been 
labouring under diarrhoea for weeks, and even months, and that this, with 
the other causes of debility, has rendered their condition exceedingly 
uncomfortable. You will also be informed by the patient, that she has 
tried many remedies without benefit, and that she is extremely anxious to 
have something done to give relief; and hence it is a matter of import- 
ance to be acquainted with any remedy which may be likely to prove 
serviceable in such emergencies. 

It would appear that this form of diarrhoea does not depend on an inflam- 
matory condition of the stomach and intestinal canal, for the indications 
of inflammation are absent, such as pain, tenderness on pressure, thirst, 
redness of tongue, and severe or continued griping. It would rather 
seem to be connected with congestion of the mucous membrane of the 
digestive tube of a passive nature, and resembling the scrofulous ; it is 
also of an unmanageable character, and very seldom amenable to the 
ordinary modes of treatment. The common astringent remedies totally 
fail ; chalk-mixture, kino, rhatany root, and cateehu, are useless, and in 
such cases it has been observed that opium is generally injurious. If you 
prescribe opium it certainly checks the disease for a time, but this tem- 
porary relief is accompanied by debility, malaise, restlessness, and many 
other uneasy symptoms, and the diarrhoea soon returns, and is as bad as 
ever. The medicine which I have found most effectual in such cases, is 
the persesquinitrate of iron, in the form recommended by Dr. Christison. 
With it I have succeeded in curing many cases which had been exceed- 
ingly obstinate and of very considerable duration, the disease having in 
one case resisted all the efforts of medical skill for seven months, and in 
the other for two years. Seven or eight drops of the liq. ferri persesqui- 
nitratis, increased gradually to twelve or fifteen in the course of the day, 
was the quantity prescribed in both cases. In the course of four days a 
slight diminution of the diarrhoea was perceived, in a fortnight the patient 
felt much better, and in a month or five weeks it had disappeared alto- 
gether. This took place without being followed by any bad effects ; there 
was no swelling of the stomach, no tympanitis, no tormina, no restless- 



570 CLINICAL MEDICINE. 

ness or nervous derangement ; the patients recovered their health and 
strength, and the cure was at once safe and permanent. 

The effect of this remedy admits of an explanation on either of two 
grounds. You are aware that nitric acid exercises a very powerful influ- 
ence over many morbid discharges. In chronic diarrhoea or dysentery, 
and in a certain form of diabetes, it is one of the most efficient and appro- 
priate medicines which can be prescribed. We can therefore understand 
its peculiar adaptation to the case of which I have spoken. The nature 
of the complaint requires a tonic as well as an astringent ; and you all 
know that nitric acid is used as a tonic in many cases attended with 
debility and emaciation. With respect to iron, its mode of action is 
equally intelligible. Many of the salts of iron exert a very remarkable 
influence on the conditions of mucous membranes. The sulphate, tartrate, 
and many other preparations are prescribed with great advantage in chronic 
fluxes from mucous membrane ; hence the benefit so frequently derived 
from the use of Griffiths' myrrh mixture in the treatment of chronic bron- 
chitis characterized by a supersecretion from the bronchial membrane, 
unaccompanied by fever. You perceive, then, both the medicines which 
enter into the composition of persesquinitrate of iron are well calculated 
to check morbid discharges and strengthen the tone of the system. The 
only objection to this remedy is, that it is apt to spoil : if kept longer 
than a week it is decomposed, and hence you should always take care 
to have it quite fresh when you prescribe it, in order to secure its full 
operation. 

I have lately had occasion to observe the good effects resulting from a 
combination of nitric acid, with vegetable astringents, in a little girl three 
years of age, in whose case I was consulted by Mr. Wallace, of Town- 
send-street. She was of a strumous habit ; her appearance was that of 
a delicate but not very sickly child, and, in spite of the long continuance 
of the complaint, she was active and lively, although her appetite was 
small. Four or five times during the day, and six or seven during the 
night, she was seized with a slight griping pain, and a sudden desire to 
evacuate the bowels. Each evacuation was scanty, and consisting of 
muco-fecal matter. A great variety of the usual remedies had been tried 
— alterative doses of mercury, purgatives, astringents, opiates, &c. I pre- 
scribed the following mixture, which had the happiest effect, and per- 
formed a speedy cure : 

R. Decocti hsematoxyli (P.D.), ^iv. 
Vini rubri Lusitanici, £j. 
Acidi nitrici dilut., gtt. x. 
Tincturae opii, gtt. v. 
M. sumat coch. j. medium, quarter in die. 

You will recollect that nitric acid, when given in large doses, often pro- 
duces diarrhoea, as in the common combination of one drachm of dilute 
acid with a pint of decoction of sarsaparilla. 

I have lately seen three cases of violent and long-continued palpitations 
in females, in each of which the same peculiarity presented itself — viz., 
enlargement of the thyroid gland ; the size of this gland, at all times con- 
siderably greater than natural, was subject to remarkable variations in 
every one of these patients. When the palpitations were violent, the 
gland used notably to swell and become distended, having all the appear- 



AFFECTION OF THE THYROID GLAND. 57] 

ance of being increased in size, in consequence of an interstitial and sudden 
effusion of fluid into its substance. The swelling immediately began to 
subside as the violence of the paroxysm of palpitation decreased, and 
during the intervals the size of the gland remained stationary. Its increase 
of size, and the variations to which it was liable, had attracted forcibly 
the attention both of the patients and of their friends. There was not the 
slightest evidence of any thing like inflammation of the gland. One of 
these ladies, residing in the neighbourhood of Black Rock, was seen by 
Dr. Harvey and Dr. Stokes; another of them, the wife of a clergyman in 
the county of Wicklow, was seen by Sir Henry Marsh ; and the third 
lives in Grafton Street. The palpitations have in all lasted considerably 
more than a year, and with such violence as to be at times exceedingly 
distressing ; and yet there seems no certain grounds for concluding that 
organic disease of the heart exists. In one, the beating of the heart could 
be heard during the paroxysm at some distance from the bed — a pheno- 
menon I had never before witnessed, and which strongly excited my 
attention and curiosity. She herself, her friends, and Dr. Harvey, all 
testified the frequency of this occurrence, and said that the sound was at 
times much louder than when I examined the patient, and yet I could 
distinctly hear the heart beating when my ear was distant at least four 
feet from her chest ! It was the first or dull sound which was thus audible. 
The sudden manner in which the thyroid, in the above three females, 
used to increase and again diminish in size, and the connection of this 
with the state of the heart's action, are circumstances which may be con- 
sidered as indicating that the thyroid is slightly analogous in structure to 
the tissues properly called erectile. It is well known that no part of the 
body is so subject to increase in size as the thyroid gland, and not unfre- 
quently this increase has been observed to be remarkably rapid, consti- 
tuting the different varieties of bronchocele or goitre. The enlargement 
of the thyroid, of which I am now speaking, seems to be essentially dif- 
ferent from goitre in not attaining a size at all equal to that observed in 
the latter disease. Indeed, this enlargement deserves rather the name 
of hypertrophy, and is at once distinguishable from bronchocele by its 
becoming stationary, just at that period of its development when the 
growth of the latter usually begins to be accelerated. In fact, although 
the tumour is very observable when the attention is directed to it, yet it 
never amounts to actual deformity. The well-known connection which 
exists between the uterine functions of the female and the development 
of the thyroid observed at puberty, renders this affection worthy of atten- 
tion, particularly when we find it is so closely related by sympathy to those 
palpitations of the heart which are of so frequent occurrence in hysterical 
and nervous females. 

Another fact well worthy of notice is, that females liable to attacks of 
palpitation almost invariably complain of a sense of fulness, referred to the 
throat, and exactly corresponding to the situation of the thyroid. This 
sensation only continues while the paroxysm of palpitation lasts, and fre- 
quently is so urgent as forcibly to attract the patient's notice, who now 
complains of its inducing a sense of suffocation. Here the interesting 
question occurs, whether this feeling of something that impedes the respi- 
ration at the bottom of the throat, during the hysterical fit, and which has 
been included under the general term globus hystericus— the question arises, 
I say, whether this feeling is always of purely nervous origin. To me it 



572 CLINICAL MEDICINE. 

appears probable that it is often induced by the pressure arising from a sud- 
den enlargement of the thyroid, which enlargement subsides as soon as the 
fit is over. Of this I am certain, that the lump in the throat, of which 
such females complain, is often exactly referred to the situation of the thy- 
roid; and, indeed, I have been told by other practitioners, upon the accu- 
racy of whose observations I can rely, that this swelling in the throat of 
females during the hysteric paroxysm has more than once excited their 
wonder. It is obvious that if palpitations depending on functional disease 
of the heart are capable of exciting this swollen state of the thyroid, we 
may expect to observe the tumefaction of this gland also where the palpi- 
tation depends on organic disease of the heart, as in the following case 
detailed to me by a friend. 

A lady, aged twenty, became affected with some symptoms which were 
supposed to be hysterical. This occurred more than two years ago ; her 
health previously had been good. After she had been in this nervous state 
about three months, it was observed that her pulse had become singularly 
rapid. This rapidity existed without any apparent cause, and was con- 
stant, the pulse being never under 120, and often much higher. She next 
complained of weakness on exertion, and began to look pale and thin. 
Thus she continued for a year, but during this time she manifestly lost 
ground on the whole, the rapidity of the heart's action having never ceased. 
It was now observed that the eyes assumed a singular appearance, for the 
eyeballs were apparently enlarged, so that when she slept, or tried to shut 
her eyes, the lids were incapable of closing. When the eyes were open, 
the white sclerotic could be seen, to a breadth of several lines, all round 
the cornea. In a few months, the action of the heart continuing with un- 
ceasing violence, a tumour, of a horseshoe shape, appeared on the front of 
the throat and exactly in the situation of the thyroid gland. This was at 
first soft, but soon attained a greater hardness, though still elastic. From 
the time it was first observed, it has increased little, if at all, in size, and 
is now about thrice the natural bulk of the fully developed gland in a fe- 
male after the age of puberty. It is somewhat larger on the right side 
than on the left. A circumstance well worthy of notice has been observed 
in this young lady's case, and which may serve to throw some light on the 
nature of this thyroid tumefaction. The circumstance I allude to is, that 
from an early period of the disease a remarkable disproportion was found 
to exist between the beats of the radial and of the carotid arteries, the pul- 
sations of the former being comparatively feeble, while those of the latter 
were violent, causing a most evident throbbing of the neck, and accom- 
panied by a loud rustling sound. In about fourteen months the heart pre- 
sented all the signs of Laennec's passive aneurism ; the tumour in the neck 
is subject to remarkable variations in size, sometimes diminishing nearly 
one-half. None of her family have had goitres, nor was she ever in any 
of the usual localities of the disease. 

Some time ago, you will recollect, we had a case of erysipelas in a young 
woman, which came on towards the termination of fever ; a similar occur- 
rence has taken place in a patient in the male fever ward. A man who 
has been for some time labouring under fever, got, about two days since, 
an attack of erysipelas of the scalp, spreading downwards over the neck 
and shoulders. The man had been ill of fever of a nervous type, and un- 
accompanied by any decided marks of visceral congestion; his condition 
was to a certain extent modified by previous habits of intemperance, but 



ERYSIPELAS— DYSPEPSIA. 573 

still his strength was not much prostrated, nor did he appear to be in a 
very dangerous state. About the fourth week of his illness he gets an 
attack of erysipelas of the scalp, which runs downwards over the neck and 
shoulders, and threatens very dangerous if not fatal consequence.**. How 
were we to treat this case? The man's constitution, habits, and the pe- 
riod of his fever, contra-indicated depletion in any form, and the only 
thing which we could expect benefit from, was the use of sulphate of qui- 
nine, which we had prescribed in two former cases of this kind with good 
effects. We gave it here, also, in the form of an enema, for the state of 
the man's stomach was such as to preclude the possibility of giving it by 
the mouth without hazard. An enema composed of five grains of quinine, 
five drops of laudanum, and two or three ounces of mucilage of Match, was 
injected three times a-day. I cannot as yet state what the result of this 
case may be, but the disease is certainly not progressing, and the man says 
he feels better to-day, so that there are grounds to hope for a favoura- 
ble termination. 

Internally I have given the man magnesia with camphor-mixture, on an 
empirical principle. It has been stated by some of the older writers, that 
when erysipelas occurs in a weak habit, or supervenes on other dist. 
that there is an acescent condition of the stomach, and that it is on this 
condition the erysipelatous tendency chiefly depends. I have with this 
view been induced to try the exhibition of small doses of magnesia ; I 
have ordered a mixture composed of six ounces of camphor-mixture with 
a drachm of magnesia, of which the patient is to take an ounce every 
second hour. 

T. may take this opportunity of observing, that since I published some 
remarks in the Dublin Medical Journal, upon the occasional symmetrical 
march of erysipelas at both sides of the median line, I have seen other 
examples of this symmetry. One occurred very lately in Sir P. Dun's 
Hospital, in a woman in w r hom the point of departure for the disease was 
the face. From this the erysipelas spread over the scalp, and then 
advanced downwards over the neck and shoulders. During its daily 
progress I pointed out to the students how precisely its outline at one 
side of the median line corresponded with that at the other. This coin- 
cidence was the more singular, for the boundary of the advancing ery- 
sipelas was at each side very irregular in form. I think, therefore, that 
more accurate observations on this subject will cause a change of opinion 
in the minds of some who at first opposed my views. 

There is another case in which I gave magnesia to a man labouring 
under a particular species of indigestion. He had been for a long time 
suffering from chronic rheumatism, and this was combined with dyspepsia, 
characterized by a tendency to supersecretion of acid in the stomach, 
w r ith gastrodynia and sour eructations. In addition to anti-rheumatic 
medicines, and enemata to keep the bowels open, we prescribed the 
subnitrate of bismuth with magnesia, for the purpose of relieving pain 
and acidity. In gastrodynia, with increased secretion of acid from the 
stomach, one of the best remedies we possess is the subnitrate of bismuth, 
with which I am in the habit of combining morphia, or, as in the presen' 
case, magnesia. I ordered ten grains of magnesia, twenty of powdered 
gum arabic, and six of the subnitrate of bismuth, to be taken two or three 
times a-day, according to circumstances ; this powder was to be fol- 
lowed by a tablespoonful of water, containing one sixteenth of a grain ot 



574 CLINICAL MEDICINE. 

muriate of morphia. In such cases, if milk does not disagree with the 
patient, you may pour the powder into a quantity of boiled milk ; allow 
it to cool, and then stir it with a spoon, and make the patient swallow it. 
The gum arabic is used for its demulcent properties, and because it 
enables the patient to swallow the powder with more facility ; and the 
fluid in which' you mix the powder, whether it be water or milk, is to be 
used warm in order to dissolve the gum more speedily. This is a very 
good combination, and I have seen many cases of dyspepsia, with acid 
eructations, which had resisted bismuth, prussic acid, or morphia, given 
singly, yield to it. 

I need not state to you the reasons why magnesia and other antacid 
remedies are given in such cases ; but it may be necessary to mention 
briefly the principle on which opiates are prescribed. Dr. Elliotson has 
shown, that many of the morbid states of the stomach depend on deranged 
nervous energy, that in such cases, the most efficient means we can use 
are narcotics. As to the subnitrate of bismuth, its mode of action is not 
very obvious ; but we know that the metallic salts possess great influence 
over various nervous diseases, as well as over morbid secretions. Witness 
the effects of carbonate of iron, oxide of zinc, the preparations of arsenic 
and antimony, and several others. On this account we prescribed the sub- 
nitrate, hoping to derive some benefit from its use, as well with respect 
to checking the sour eructations, as to relieving the gastrodynia. It may 
be well to make a few observations in explanation of the manner in which 
tonics and narcotics act in diseases of the stomach. Formerly physiolo- 
gists were of opinion, that in weakly stomachs the act of digestion was 
accompanied by the formation of acid and flatulence, because the food 
being imperfectly acted on, was allowed to undergo the process of fer- 
mentation, a process which gave rise to the acid and the wind in the 
stomach. In compliance with this view, physicians endeavoured to pro- 
cure relief in these cases by prescribing a regimen little likely to undergo 
a fermentation capable of causing a production of either air or acid ; and 
they endeavoured to neutralise the bad effects of these, when produced 
by means of the administration of alkaline medicines. They used, how- 
ever, to be astonished at observing that many articles of food, which 
outside the body never formed any acid during the fermentation (or 
more properly putrefaction), occasioned, nevertheless, when eaten, as 
much acidity in the stomach as any other aliments. 

It was remarked also by practical men, that although present relief was 
obtained by means of alkalies, yet their constant exhibition seemed rather 
to increase than diminish the tendency of the formation of acid in the 
stomach. This fact could not be explained in the then state of physio- 
logy. In the year 1821, I read an essay on this subject before the Asso- 
ciation of the King and Queen's College of Physicians, in whose transac- 
tions it w T as subsequently published. In this essay I pointed out the true 
source of the acidity and flatulence observed in dyspepsia, and proved, 
contrary to the received opinions, that it was the result of a morbid se- 
cretion. In fact, I showed that the stomach has the power, when in 
health, of secreting acids and air, both essentially necessary for the solu- 
tion of the alimentary mass ; and I proved, that in dyspepsia this power 
is morbidly deranged in such a manner as to give rise to a supersecretion 
of acids and air. This view of the subject was soon recognised to be 
correct, and in consequence, new methods of treating dyspepsia were pro- 



psoriasis. 575 

posed. Among the proposals for obviating acidity, that of Dr. Elliotson, 
who recommended prussic acids and other narcotics capable of acting 
upon the nerves of the stomach (through the influence of which secretion 
is effected), was found to be the most successful, and has been sanctioned 
by the most extensive experience. 

Before I conclude I shall call your attention to the case of Ellen Far- 
row, who has been for a considerable, time labouring under extensively 
diffused psoriasis. She was admitted about the beginning of last Novem- 
ber, and we are now come to the 10th of December ; so that she has been 
a patient here for nearly six weeks. Her disease is of better than two 
years' standing, and the eruption covered almost every part of the surface 
of the upper and lower extremities, the trunk remaining unaffected. The 
patient, you perceive, is a fine healthy country girl ; and though the com- 
plaint has lasted so long, her system does not seem to be in the slightest 
degree impaired — appetite, digestion, and sleep are perfectly good. Now, 
on examining her soon after her admission, you will recollect that I told 
you that the duration of the disease, the absence of constitutional irrita- 
tion, and of irritation in the parts affected by psoriasis, all contra-indicated 
a mode of treatment which frequently proves highly useful, namely, the 
antiphlogistic. If called to a case in which the disease was recent, and 
attended with heat of skin, redness, and itching, I would bleed, leech the 
affected parts, and put the patient on a spare diet. Even in some cases 
of a chronic character, this treatment may be employed with great advan- 
tage. Here, however, the state of the patient was such as not to require 
antiphlogistics, and accordingly we put her on the use of Fowler's arse- 
nical solution. By the way, when you give this remedy in private prac- 
tice, where patients or their friends are very curious in scanning your 
prescription, you may, in order to prevent alarm, or have the action of 
the medicine interfered with, write on your prescription — " Liquor mine- 
ralis Fowleri." 

I mention this case of Farrow's chiefly for the purpose of showing the 
extent to which the arsenical solution may be carried. Bear in mind, I 
do not mean to boast of the quantities of medicine my patients swallow. 
Some persons appear to think, that there is something very brilliant in 
prescribing enormous doses : I should, however, be very sorry to make 
such experiments. Arsenic is a very powerful remedy, and its effect on 
diseases of the skin can be amply secured by moderate doses ; where 
these fail, it is very often from not continuing the use of the remedy for 
a sufficient length of time. Latterly this girl has taken ten drops of Fow- 
ler's solution three times a-day ; and, as she is getting well, I do not in- 
tend to increase the dose. We began with three drops three times a-day ; 
after a few days this was increased to five, and then to seven drops three 
times daily. She then began to take ten drops three times a-day ; but 
after a few days having got an attack of shivering, followed by symptoms 
of feverish excitement and herpes labialis, we stopped the arsenic for five 
days, and then began to give it again in small doses, which were gradu- 
ally increased until we came to the quantity she is taking at present. 
Whenever you have a patient under the use of arsenic, you must never 
omit making daily inquiries as to the state of the head and stomach ; if 
the patient complains of gastrodynia or nausea, if there be pain or giddi- 
ness of head, or if, these being absent, a state of feverishness or general 
nervous excitement supervene, it is a proof that the remedy has been 



576 CLINICAL MEDICINE. 

pushed sufficiently far, and under such circumstances you should suspend 
or give up its employment. In this case, being unwilling to give up the 
use of arsenic, as it appeared to be curing the patient, I merely suspended 
it for a few days, and then had recourse to it again. In order, however, 
to prevent it from acting unfavourably on the stomach, I have latterly 
prescribed it in the following form : — 

R. Liq. arsenicalis, M. x. 
Aquae distillatse, 5J. 
Thick opii, M. x. 
Spirit. lavandulse, compos, ^ss. — ft. haust. 

This appears to agree very w r ell with the stomach ; and as she is improv- 
ing very rapidly, I intend to continue it for some time without increasing 
the dose. 

The only other point worthy of remark in the case is, that we observed 
in it a phenomenon connected with the state of the skin, such as usually 
occurs when a patient is using sulphur or sulphureous waters for the cure 
of chronic cutaneous affections. After they have been taking these reme- 
dies for some time, they experience a slight exacerbation of symptoms, and 
complain that the eruption is growing worse. This, however, should 
never induce you to give up the remedy without further trial ; for this tem- 
porary aggravation generally precedes the disappearance of the disease. 

We dismissed a case of dysentery lately from our wards, concerning 
which I promised to make a few observations. During the months of 
August and September last, w r e had in Dublin several cases bearing a de- 
cided analogy to the dysentery of Cullen. There were fever, griping, 
tenesmus, a constant inclination to go to stool without being able to pass 
any thing but a little mucus and blood, and occasionally scybalae. In this 
form of disease, some authors are inclined to attribute all the bad symp- 
toms to the presence of these scybalae, which are small hard lumps of fecal 
matter, evidently formed in the sacculi of the great intestine. You will 
find others asserting that this cannot be the case ; for in many dysenteries 
there are no scybalae at all, and that even when they do occur, they have 
no connection with the disease. The latter take no account of scybalae, 
while the former state that the diseased condition of the intestine depends 
upon the irritation produced by them, and that you never can expect to 
cure the disease without getting rid of them by active purgatives. For 
my part, I believe that there are certain dysenteric states of the great in- 
testine, in which the main cause of the disease arises from the lodgment of 
quantities of hard, unhealthy, and long-retained fecal matter; but in cases 
of epidemic dysentery, I do not think that scybalae have any thing to do 
with the formation of the disease, or the aggravation of its symptoms. 

In the present case, the affection appears to have been pure rectal dy- 
sentery, depending almost exclusively on inflammation of the rectum, not 
extending to the sigmoid flexure of the colon, and certainly never as fai 
as its arch. The symptoms present were fever, increased heat of skin and 
quickness of pulse, with a feeling of heat and pain in the situation of the 
rectum ; for the first day the discharges consisted of mucus and blood, com- 
bined with fecal matter, but after this the mucus and blood were voided 
alone with great griping and tenesmus, and the patient was obliged to get 
up to the night chair thirty times in the course of twenty-four hours. 
There was, however, no symptom indicating that any portion of the intes- 



PLEUROPNEUMONIA. 577 

tine beyond the rectum was affected. Now, what was the consequence 
of this state of things? The inflammation of the rectum gave rise to con- 
stant spasm of that organ ; the colon partook more or less in its spasmodic 
action, and hence every attempt to pass the stools was resisted. Here, 
however, the feces lay in a portion of the intestine free from inflammation; 
they could not produce any aggravation of the symptoms, and the scybalae 
were to be looked on as the consequence and not the cause of the disease. 
Now, whether purgatives were given by injection, or by the mouth, they 
would have done no good in such a case as this; we might have copious 
fecal discharges, but without the slightest diminution of the local symp- 
toms. I do not mean to say that there are not dysenteries in which pur- 
gatives are highly useful ; but in the case before us, where the disease was 
limited to the rectum, I did not think that any benefit could be derived 
from them. I confined my attention, therefore, entirely to local means 
directed to the part inflamed, applied leeches to the anus, gave narcotic 
and emollient enemata, and after I had in this way relieved pain and irri- 
tation, I combined with the enemata, first, a small quantity of the acetate 
of lead, with the view of restoring the tone of the relaxed mucous mem- 
brane, and afterwards changed it for the sulphate of zinc. Under this 
treatment the case went on very favourably, and we have been able to dis- 
miss the man in a very short space of time. 



LECTURE XLIII. 



Pleuro-pneumonia — Cases of latent pleurisy; of pneumonia — Phthisis; latent ulceration ot 
the bowels in — Diarrhoea of phthisis — Observations on the stammering of paralytic persons 
— Its explanation — Very remarkable case of stuttering cured by chronic laryngitis — Treat- 
ment of hoarseness — Velpeau's method of treating sore throat. 

Let me now direct your attention to another topic. You have seen that 
a principal feature in the character of the present pneumonia is its compli- 
cation with pleuritis ; we have had several cases of inflammation of the 
lungs, combined with inflammation of their investing membranes, but I do 
not recollect that we have had a single case of pure pleuritis, or pure pneu- 
monia. In the patient who lies at present in the chronic ward, labouring 
under pleuro-pneumonia, the inflammation occupied the superior part of 
the right lung in the first instance, and this is rather remarkable, as pneu- 
monia generally commences in the lower part of the lung. Here, however, 
the pneumonia and pleuritis were located above, each being in point ol 
extent nearly of the same dimensions, the portion of inflamed lung corre- 
sponding in its area to the portion of pleura engaged in the disease. Soon 
after his admission we found that the inflammation was making further 
progress, but its spreading was attended with this remarkable peculiarity, 
that while the pleuritic inflammation in the superior part of the right side 
of the chest became limited and ceased to extend itself, the pneumonic 
inflammation commenced travelling downwards and backwards, so that 
alter two or three days we had pleuro-pneumonia in the upper part of the 
lung, and further down in the lower and back part of the lung it was 
merely pneumonia unaccompanied by pleuritis. This is an occurrence 
which I have frequently witnessed, that when pleuritis and pneumonia co- 
38 



578 CLINICAL MEDICINE. 

exist, the latter will spread, often in spite of all our efforts, while the former 
remains stationary. I wish to impress this fact on your minds, that pleu- 
ritis never exhibits such a tendency to extend itself gradually, day after 
day, as pneumonia; if the pleura becomes inflamed, the extent to which 
it is likely to be engaged will be determined in twenty-four hours ; whereas, 
in cases of pneumonia, the disease, though limited at the commencement 
to one or two small insulated spots, will frequently begin to extend in every 
direction from these points, until in the course of a few days it involves a 
large portion of the lung. In other cases, many days are required before 
the spreading of pneumonia ceases. 

This case is of considerable interest to the stethoscopic student, as ex- 
hibiting in a very satisfactory manner all the physical signs of pneumonia, 
as well in its pure state as where it is complicated with pleuritis. It is 
unnecessary for me to enter into any detail of the symptoms or of the 
physical signs, but I invite you to study them as well worthy of your 
attention. 

A patient has recently died, who came into hospital labouring under a 
disease which generally proves fatal, namely, double pleujo-pneumonia. 
He had violent pleuritis and pneumonia in both sides of the chest under 
these peculiar circumstances ; that in the left side the pneumonia was 
situated above and anteriorly, in the right side below and posteriorly ; so 
that the lungs were affected nearly at the opposite ends of their transverse 
diameters. On his admission, he appeared extremely low and weak, and 
it was obvious that the case must terminate fatally. His respiration was 
extremely quick and laboured ; he had great oppression about the chest, 
constant anxiety, incessant harassing cough, quick weak pulse, and a 
countenance expressive of intense suffering. On examining the chest 
with the stethoscope, we found that both lungs were extensively solidified ; 
and this, combined with his age, and the manifest sinking of the powers 
of life, prevented us from indulging in any hope of being able to arrest, 
much less to remove, his complaint. He was a poor creature, moving in 
the very lowest class of life, ill fed, without sufficient clothing, most 
wretchedly lodged, and constantly exposed to cold and hardships. He 
had been employed in breaking stones on a road at fourpence per day, 
and out of this miserable pittance endeavoured to maintain a family. 
From repeated exposure to inclement weather, he got a violent attack of 
pleuro-pneumonia, which, being neglected at the commencement, assumed 
an intractable character, and when he came into hospital, the disease had 
been of several weeks' standing, his system reduced to the lowest state, 
and no sign whatever of reaction. 

In estimating the danger of a patient labouring under pneumonia, I have 
tohi you that it is not so much in proportion to the extent of lung engaged, 
as to the quickness of respiration, and the presence or absence of symp- 
toms of asphyxia. You will see one man in pneumonia, having nearly 
the whole right or left lung inflamed and solidified, breathing easily with 
the other lung and apparently suffering but little inconvenience ; while 
you will find others, with a smaller amount of disease, exhibiting symp- 
toms of distress bordering on asphyxia. I attended a young gentleman 
eighteen months ago, w T ho had complete carnification of the left lung, and 
pleuritic effusion on the same side, pushing the heart so far out of its 
place, that it could be felt pulsating under the right mamma. His illness 
lasted for nearly four months ; yet the fluid was afterwards completely 



PHTHISIS SENILIS. 579 

absorbed, the lung gradually assumed its natural condition, and he reco- 
vered perfectly. About six months after, I was again called to see him, 
and found that after exposure to cold he had got a violent attack of pneu- 
monia in the right lung, which had run on to hepatization, and on exam- 
ining him by the stethoscope and percussion, I found that almost the whole 
of the lung was solidified. In this case, there never was any thing like 
an approach to asphyxia ; indeed, the distress of breathing was extremely 
slight, and he recovered completely in two months. This was rather a 
singular case ; the patient one year getting violent pleuritis, followed by 
extensive effusion, forcibly compressing the lung so as to render it quite 
useless, and pushing the heart out of its place ; and the next year getting 
an attack of pneumonia in the other lung, ending in solidification of nearly 
the whole organ, and yet recovering completely from both. I need not 
say that there could have been no scrofulous taint in this gentleman's 
constitution, for if there had, the chances were that he would have sunk 
under either of these attacks. He lives at Crumlin ; and in both instances 
his attending physician was Dr. Adams, of Stephen's Green. 

In such a case as this, the utility of the stethoscope was obvious ; by 
its means we not only learned the nature and extent of the disease we 
had to combat, but also the exact situation where topical applications, 
such as leeches, blisters, setons, &c, should be applied with greatest ad- 
vantage. I had lately an opportunity of witnessing an extremely inte- 
resting case of perfectly latent pleurisy. It was seen in the first instance 
by my friend and former pupil, Mr. B. Guinness. A fine young gentle- 
man, catching cold, contracted some slight fever apparently catarrhal, 
which altogether subsided in five or six days, but he remained very weak. 
I saw him on the tenth day ; a very slight cough remained, his breathing 
was regular, and he felt no want of breath ; he had had no pain in the 
side from the commencement ; he was weak and rather sleepless ; other- 
wise he could specify no complaint. I do not know what induced me to 
percuss his chest — perhaps it was the force of habit ; be this as it may, 
percussion led me to the discovery of extensive pleuritic effusion on the 
right side. He recovered perfectly under the use of proper remedies. 

Let me now direct your attention for a few moments to the case of M. 
Murphy, who died on Saturday last. This man, aged sixty, was admitted 
on the first of November. He had been ill for nine months before his 
admission, and stated that his illness originated in exposure to cold. It 
commenced with cough, oppression of chest, dyspnoea, and haemoptysis. 
During the first month, the haemoptysis recurred frequently, and, as he 
thought, generally with more or less relief; but during the latter period 
of his illness, it was entirely absent. On his admission, he had well- 
marked hectic fever, with copious puriforra expectoration, and appeared 
very much emaciated. The right clavicle sounded pretty clear, but 
under the left clavicle there was well-marked dulness, with a full mucous 
rale approaching to gargouillement and pectoriloquy. The two latter 
symptoms became much more decided in about a week after his admis- 
sion, and I accordingly marked on his card " Phthisis Senilis." The 
only other circumstance connected with the history of his case which 
deserves attention, was, that he laboured under constant costiveness, 
which continued up to the period of his death, his bowels never yielding 
except when he used purgative medicines. 

It is unnecessary for me to enter into a detail of the remedies employed 



580 CLINICAL MEDICINE. 

to alleviate his symptoms— the only duty which remains for the physician 
under such circumstances ; I shall therefore content myself with noticing 
the phenomena observed on dissection, with one or two particulars which 
seem to demand a brief observation. You will recollect that this man 
exhibited, for several weeks before his death, unequivocal signs of a large 
cavity in the left lung, and that latterly the right lung also had become 
dull on percussion, and that the stethoscopic phenomena indicated the 
formation of a new cavity at its upper portion. Here are the lungs ; the 
left, you perceive, is larger than the right, and exhibits a marked depres- 
sion at its upper portion, where the phthisical cavity is situated. You 
perceive also, that the pleura investing it is very much thickened, and 
very rough on its surface ; this appearance was in consequence of its 
intimate and universal adhesion to the corresponding pleura costalis, from 
which it was separated with considerable difficulty. You perceive that 
the right lung is rather smaller than the left ; the left, being rendered 
more extensively solid by disease, has become incapable of collapsing 
after death to the same extent. We shall now make a section of the lung, 
to show the extent of the cavity. Here is the cavity; yon perceive that 
it is nearly large enough to contain a small orange, and that its walls are 
lined with a firm semi-cartilaginous membrane. At the upper and internal 
part there is a small opening, which seems to be the commencement of a 
fistulous passage, a very common occurrence in cases of phthisis senilis ; 
I shall introduce a probe and lay it open. Here is the track of this fistu- 
lous opening, and you perceive it terminates in one of the large ramifica- 
tions of the left bronchus. You may perceive, also, that the section I 
have made displays masses of small granular tubercles in the upper and 
anterior portion of the lung, quite different in size and appearance from 
the large tubercles seen in the child and adult. I shall now make a 
section of the right lung. It is much more natural in its feel and appear- 
ance than the left, but still in all chronic cases of phthisis we seldom have 
the disease limited to a single lung. Here you perceive are a few patches 
of granular tubercles, looking as if they were infiltrated into the substance 
of the lung, and not surrounded as the large tubercles of the adult and 
child are, by vascular condensed pulmonary tissue. Here, you see, I 
have cut into a small cavity ; from its contents and appearance, you can 
judge that it is of comparatively recent formation ; it has no semi-carti- 
laginous lining, and is of very inconsiderable size. You perceive, also, 
that it communicates freely with a pretty large sized bronchial tube, and 
contains a quantity of muco-purulent secretion. 

With respect to the state of the viscera of the abdomen, I may observe, 
that with the exception of some portions of the intestinal tube, which I 
am about to show you, they presented nothing very remarkable. The 
liver and kidneys were found to be of the natural size, somewhat indu- 
rated, and very friable, and the spleen exhibited several small tubercular 
spots on its surface. Here are the stomach and the duodenum, which 
you perceive retain their normal appearance ; and the same, remark is to 
be made of the colon and rectum. In the ca?cum, however, which you 
see here, and here also in the ileum, there are several ulcerated patches 
of an oval form, and corresponding to the situation of the glands of Peyer. 
In some places you perceive the ulcers have destroyed not only the mucous 
membrane, but also the muscular coat of the intestine, and have very 
nearly produced perforation. 



LATENT ULCERATION OF THE INTESTINES. 581 

A most important inference may be drawn from this fact. Here we 
have several ulcers destroying the mucous coat of the intestine, and eating 
their way through its muscular tissue, so that the only barrier left to 
prevent an effusion of the intestinal contents into the cavity of the peri- 
toneum, is a thin layer of serous membrane. Yet, during the whole time 
he remained in the hospital, his bowels were so obstinately costive, that 
we were obliged to give him purgative medicine every second or third 
day, to procure an evacuation. You would suppose, a priori, that a man, 
in whom ulceration of the bowels existed, would suffer considerably from 
pain, griping, and tympanitis, and that he would labour under the diar- 
rhoea so frequently observed in the advanced stage of phthisis. Our pre- 
decessors entertained a notion that the diarrhoea of phthisis is a species of 
internal sweating ; they observed, that when the patient ceased perspiring 
from the skin, he was generally attacked with a watery diarrhoea, and 
hence they termed the diarrhoea, colliquative. Afterwards it was found, 
on numerous examinations, that where this diarrhoea had existed, there 
was in most cases ulceration of the bowels ; hence pathologists began to 
believe that this ulceration had a great deal to do with the intestinal 
symptoms observed towards the termination of phthisis, referring to it the 
abdominal pain and tenderness, the unmanageable character of the diar- 
rhoea, and the aggravation of the hectic symptoms. 

Now it strikes me that this mode of accounting for these symptoms was, 
perhaps, too hastily adopted. No doubt ulceration of the bowels may 
produce all the symptoms detailed ; but, on the other hand, it may exist 
to a very remarkable extent, and yet produce no symptoms by which it 
could be recognised. Here was a patient who never had the slightest 
tendency to diarrhoea, who never complained of pain, griping, flatulence, 
or abdominal tenderness ; on the contrary, his bowels were not merely 
slow, but even confirmed])- costive, and he always felt more or less relief 
from the use of purgative medicine. None of us ever suspected that any 
thing like ulceration existed ; we gave him a full dose of castor oil every 
second day, which produced one rather scanty evacuation, and yet when 
we come to examine his intestines, we find numerous patches of ulcera- 
tion. This case is calculated to make a deep impression on every reflect- 
ing mind ; in a practical point of view, it is of great importance. If the 
scrofulous disease had in this case been entirely limited to the bowels, 
and had not touched the lung, the great probability is that it would have 
been almost wholly latent ; that the man would have taken no notice of 
it, would have thought himself well, and eaten, drunk, and worked as 
usual ; that the disease would have gone on stealthily committing its 
ravages, and that one of the first symptoms of danger would have been 
the occurrence of perforation, followed by universal and fatal peritonitis. 
The question would then be as to the cause of death. The pathologist 
would open the body, and find at once that the cause of the whole mis- 
chief was ulceration of the intestines ; but he would be mortified to think 
that the work of destruction had gone on silently and unobserved, and 
that it could not be recognised until a new disease appeared, under which 
the patient sank. I have read of more than one case in which a person 
killed by accident was found to have large ulcerated patches in the ileum, 
and yet had not been known during life to complain of any intestinal 
symptoms. In one case, a strong and apparently healthy Lascar, who 
had eaten heartily an hour before he was killed, and whose digestion was, 



582 CLINICAL MEDICINE. 

according to his friends' account, unaffected by any morbid derangement, 
presented, on examination, a number of deep ulcers in the ileum, which 
would in all probability have ended in perforation and peritonitis in the 
course of a few days. 

At the conclusion of this lecture I intend to speak of hoarseness and 
chronic laryngitis, and shall most probably return to this interesting topic 
again. At present I shall detain you for a few moments with a brief out- 
line of a case of total loss of voice, which I have recently witnessed, and 
which is in itself so singular, that I make no apology for giving it. 

Before I mention this case, allow me to observe that loss of speech 
arises sometimes from lesions of apparently a very trifling character. A 
person may totally lose his speech without any previously existing or pre- 
monitory symptoms indicative of nervous lesion — without having expe- 
rienced any sensation of pain or vertigo, any noise in the ears, any indi- 
cations of determination to the head — in fact, without any thing to show 
that the aphonia was connected with any particular state of the brain. 
Thus, a barrister, whom I attended with Dr. Beatty, was walking up and 
down the hall of the Four Courts, waiting for a case to come on, and 
chatting with one friend and another ; as the hall was rather crowded and 
hot, he went out into the area of the courts for the sake of the air, and 
had not remained there more than ten minutes when an old friend from 
the country came up and spoke to him. He was pleased to see his friend, 
and wished to inquire about his family, when he found, to his great sur- 
prise, that he could not utter a single audible sound ; he had completely 
lost his voice. He recovered the use of his tongue in about three weeks, 
but not completely, for some slowness of speech remained. When the loss 
of speech was first perceived, his friend brought him home in a carriage ; 
and during the day he had several attacks of vertigo, and afterwards he- 
miplegia. For several hours, however, before distortion of the face or 
any of the usual symptoms of paralysis had commenced, the only existing 
symptom was loss of speech. This gentleman died of apoplexy in about 
two months. 

In many cases of paralysis you will find that, although the patients have 
lost the .power of utterance, yet the motions of the tongue appear to be 
nowise deranged. In the majority of cases it can be shortened, elongated, 
raised, depressed, or moved from side to side, with as much apparent 
facility as in a state of health ; and yet the voice is in some instances 
very much impaired — in others, totally lost. In such cases it would ap- 
pear that the defect lies in the glottis, which forms and modulates the 
voice, and not in the tongue or lips, which divide and articulate it. In- 
deed, this is evident to any one who observes the interrupted and spas- 
modic efforts which paralytic persons make when speaking ; they are, in 
fact, all stutterers. 

But to return to the ca c e to which I have alluded. A young gentleman 
of delicate constitution, and who is now about sixteen years of age, con- 
tinued to enjoy tolerably good health up to his sixth year. When about 
six years of age, he went to bed one night in health and without any un- 
usual symptom, but on getting up in the morning it was observed that he 
had lost his speech, and was unable to articulate a single word. His 
family became alarmed, and sent for a physician immediately; the boy 
got some internal medicine and a stimulant gargle, and recovered his 
speech in a few days, without the occurrence of any symptom of laryngeal 



H0ARSENE8S AND LOSS OF VOICE. 583 

inflammation or cerebral disease. But what was remarkable in the case 
was this: the boy, who up to this period had spoken well and distinctly, 
now got a terrible stutter. This resisted all kinds of treatment, and for 
ten years he continued to stammer in the most distressing way, and was 
so annoyed by it himself that, when a boy, he used to stamp on the ground 
with vexation whenever he failed in uttering what he wished to express. 
In the month of May last he got an attack of chronic laryngitis of a scro- 
fulous character, and evidently the precursor of phthisis. Indeed, he is 
at present labouring under phthisis ; Dr. Stokes and I have examined 
him, and we feel convinced that tubercular deposition is going on in the 
lungs. But what is most curious in the case is this: after he got the 
laryngitis, a very peculiar change took place ; the laryngeal inflammation 
modified the tone of his voice so as to make it a little husky, but the 
stammering has completely ceased. 

You are aware that stammering has been explained as depending on 
spasm of the muscles which are employed in modifying the column of air 
as it rushes through the narrow aperture of the glottis. At certain times, 
and under a variety of circumstances, those fine muscular organs become 
spasmodically affected, the vocal chords no longer undergo the same steady 
and exact tension and relaxation, and speech becomes interrupted in con- 
sequence of frequently-recurring closure of the glottis. With respect to 
this disease, I would beg leave to refer you to a very excellent chapter in 
Dr. Arnott's work on the Elements of Physics, vol. i. p. 644. 

In the case to which I have referred, inflammation taking place in the 
mucous membrane covering these delicate muscular fibres, you can con- 
ceive that either the thickening of the mucous membrane, or the alteration 
in the state of its vitality, may have so modified the disposition of the 
parts, that they become incapable or indisposed to undergo those rapid 
contractions necessary to produce stammering, by inducing closure of the 
glottis at the moment that its aperture ought to remain open. The case 
itself, however, is an extremely curious one, and I do not believe that 
there is any similar one on record. Every thing which bears on the cure 
of so important a disease as stammering, even though it be accidental, 
and not the result of medical care and ingenuity, is of great value, inas- 
much as it tends to place the causes of the disease in a clearer light. In 
this point of view I look upon the case as one of very great interest. 

I shall conclude this lecture with a few detached observations on hoarse- 
ness, or loss of voice, from sore throat or slight laryngeal inflammation — a 
form of disease which is now very prevalent. 

A form of hoarseness is frequently observed in growing boys or girls, 
which assumes a very chronic character, and often resists for a long time 
almost every form of treatment. A boy gets cold, followed by sore throat 
and feverish symptoms, w r hich may last for a few days, and then disappear 
under the use of aperient medicines, or perhaps without any interference 
on the part of the parents or the physicians. The feverishness and sore- 
ness of throat subside, but the hoarseness remains, and the boy can speak 
only in whispers. This condition may last for weeks, and even months, 
without any other symptoms whatever ; the patient has no cough or diffi- 
culty of breathing; his appetite is good, sleep and digestion natural, and 
there is no appearance of emaciation. The only thing amiss with him is 
the impairment of voice, and this continues so long that it gives rise to a 
considerable degree of anxiety on the part of his parents. When you exa- 



584 CLINICAL MEDICINE. 

mine the fauces, you find no appearance of inflammation in the mucous 
membrane, and there is no superficial or deep-seated tenderness in the re- 
gion of the larynx. How are you to treat this form of disease? It de- 
pends on a relaxed and weakened state of the chordae vocales, and perhaps 
the muscles of the larynx — the result of inflammation of an exceedingly 
chronic character — and will not be benefitted by leeches, or antiphlogis- 
tics, or low diet. The best thing you can do in such a case is to have re- 
course to the use of strong stimulant gargles. You begin with a drachm 
of the tincture of capsicum in six ounces of decoction of bark, which is 
to be used five or six times a-day. After some time you can increase the 
quantity of tincture of capsicum, but you never need go farther than half 
an ounce in a six-ounce mixture. In the next place, you will have re- 
course to frictions over the region of the larynx and external fauces with 
croton oil, which is much better adapted for such cases than tartar-emetic 
ointment. The eruption produced by tartar-emetic ointment is productive 
of a great deal of annoyance, and when the pustules break they prevent 
the boy from wearing his neckcloth. All the purposes of a counter-irri- 
tant are quite as well fulfilled by croton oil, and with much less inconve- 
nience. The best form for using it is the following : — 

B=. Liniment: camphorse comp., ^j. 
Olei crotonis tiglii, M. xx. 

Of this mixture a small quantity, say a couple of drachms, should be poured 
into a saucer, and rubbed over the fore part of the neck night and morn- 
ing, until a full crop of pimples appears. When these have dried up and 
desquamated, it should be again applied, and in this way a mild and man- 
ageable, but very effectual, degree of counter-irritation can be kept up for 
any length of time. In addition to these measures (should the disease con- 
tinue), I would strongly recommend small doses of iodine, and change of 
air. I have been induced to give iodine in such cases from observing 
that inflammation of a chronic character seems to have many points of re- 
semblance to that which arises from scrofula. The last thing which I have 
to observe on this form of hoarseness is, that you should, particularly in 
the beginning, insist on the observance of strict silence — a point which is 
said to be exceedingly hard to be attained where the patient happens to 
be a female. In some cases all these means fail, and then something more 
energetic must be attempted. The inhalation of the vapour arising from 
tincture of iodine and tincture of conium, added to hot water in a proper 
apparatus, has proved useful to some; but in all obstinate cases the sheet- 
anchor is mercury exhibited internally, and by means of inhaling the fumes 
of hydrargyrum cum creta. In general, it is necessary to continue the 
mercurials until the mouth is slightly touched, when the hoarseness will be 
found to yield. It is obvious that, before we employ mercury in a case of 
chronic hoarseness, we must feel well assured that we have not to deal with 
a hoarseness arising from a phthisical tendency, for in this case mercury 
would prove injurious to the constitution. In such cases the stethoscope 
and percussion often afford valuable assistance, by showing that although 
the patient has had a hoarseness and cough for weeks, or even months, 
yet there are no symptoms of tubercular development in the lungs. The 
cough is only the result of laryngeal inflammation or irritation; the sub- 
maxillary glands and the amygdalae are often slightly enlarged, the fauces 
are red, and the back of the pharynx is covered with irregular superficial 



AMAUROSIS. 585 

excoriations. Connected with the subject of sore throat is the discovery, 
lately announced by Velpeau, of the use of alum in powder in acute cy- 
nanche tonsillaris. He states that this powder, applied by means of the 
ringer to the fauces and inflamed parts, exercises a wonderful effect. The 
symptoms, says Velpeau, are stopped as if by enchantment, the fever dimi- 
nishes, the redness and tumefaction of the inflamed parts subside, the ap- 
petite returns, and convalescence is speedily established. This applica- 
tion is successful at any period before suppuration has been established. 
Alum has long since been applied in substance to the throat, in cases of 
angina maligna, and in chronic sore throat; but, before Velpeau, no prac- 
titioner ever dreamed of making use of alum as a local application during 
the first stages of acute cynanche tonsillaris. By the way, this use of alum 
is calculated to throw some light on the good effects which this substance 
exerts, when taken in large doses, in cases of violent pain in the stomach 
arising from indigestion, recommended by Dr. Griffin, of Limerick. 



LECTURE XLIV. 

Amaurosis — Acetate of lead in Asiatic cholera — Remarkable mobility of sternum. 

There is at present in the hospital, a man whose case has been marked 
imperfect or (to use a better phrase) incomplete amaurosis. He has been 
complaining at different times during the past year, and for the last six 
months his vision has been very weak, with the exception of occasional 
intermissions. He can perceive objects tolerably well with the right eye, 
but scarcely at all with the left, and in both vision is more or less dim 
and imperfect. 

On examining this man's eyes, you cannot discover in either of them 
the slightest perceptible defect as an optical instrument. The deficiency 
of vision, therefore, does not depend on opacity of the cornea, on disease 
of the lens or its capsule, or on any alfection of the aqueous or vitreous 
humours ; it is simply an impairment of the vitality of the organ, con- 
nected with functional disease of the retina. Having thus satisfied our- 
selves as to the seat and nature of the disease, we come next to inquire 
into its cause and origin. From a careful examination of the man's state 
of health, we can have no doubt on our minds as to whether the amaurosis 
in this case has been produced by derangement of the stomach or not. 
You are all aware that the celebrated Richter has long since shown, 
that functional disease of the retina is often connected with a deranged 
state of the alimentary canal, and that it may be treated successfully with 
emetics and purgatives. Here, however, we have no evidence of the 
existence of congestion or derangement of the stomach and bowels. The 
man's appetite is good, his bowels regular, and his health robust. But 
when we come to examine the head, we find evidence of cerebral con- 
gestion sufficient to account for the functional lesion of the optic nerve. 
Our patient has been a long time complaining, at different periods, of a 
sense of fulness in the head, and is subject to attacks of vertigo while 
walking, causing him to stumble occasionally, and labour under frequent 
apprehensions of falling down in the street. He prefers walking along 



586 CLINICAL MEDICINE. 

the middle of the street to either side, and says that he is always worse 
when he attempts to walk along the flagway. This is an ordinary symptom 
observed among persons who have a tendency to vertigo ; they are fre- 
quently made worse by the operation of causes in themselves apparently 
inconsequential, and the nature of which we cannot well understand. 
You are aware that, in many persons, the act of looking for any length of 
time at objects moving rapidly in a straight line, and still more in a circle, 
has a tendency to produce giddiness. Thus, looking out of the window 
of a steam-carriage on the objects apparently moving backwards with 
great velocity, or looking over a bridge at the current of a rapid river, or 
gazing at a person whirled round in a gyrating swing, is very apt to give 
rise to vertigo. Again, persons labouring under a morbid sensibility of 
the brain, very often become giddy from looking at a succession of objects 
moving with much less rapidity. Hence you will find such persons made 
giddy by walking through a crowded city, and having a number of persons 
pass by them on the flagway, and they seek for an opportunity of getting 
into the middle of the street, to avoid meeting so many objects. I knew 
a person who could never pass by a line of railing with any degree of 
comfort; if he happened to look at them as he moved by, he became 
almost immediately vertiginous. Giddiness is also generally produced 
by looking down from a great height, in a vertical direction, or by looking 
upwards, provided the object be immediately overhead, and at a great 
distance. Under these circumstances, most persons experience a feeling 
of vertigo, no matter what their position may be at the time. There 
seems to be little doubt that the sensation of giddiness does not depend 
merely on the distance or position of the object looked at. It would 
appear that, in general, some continuous communication must exist 
between that object and the spectator. Thus we feel giddy when we 
look down from a precipice at something below, or when standing beneath 
the dome of St. Peter's or St. Paul's we regard with attention the vaulted 
structure above ; but we do not feel giddy when we look down from a 
balloon, or look upwards at the moon or stars near the zenith. It has not 
been sufficiently remarked by writers, that persons subject to vertigo are 
often almost as much affected by looking upwards as by looking down- 
wards. Persons who are inclined to vertigo, will also become giddy by 
directing the eye with a fixed attention for any length of time to the one 
object, — such as continuing to look in a straight line, or endeavouring to 
direct the course of their movements along a plank of narrow pathway. 
These circumstances are alt very difficult to explain, and I bring them 
forward merely as illustrating the fact of this man's preference for walking 
in the middle of the street. 

In this man, as you may have perceived, we had several circumstances 
calculated to direct our attention to the state of the brain as connected 
with the impairment of vision ; besides vertigo, and a tendency to stumble 
in walking, he had flashes of light before his eyes, and other luminous 
hallucinations, with tinnitus aurium on one side. With respect to the 
flashes of light before the eyes, I may observe, that they may be produced 
by the operation of various causes ; a blow or pressure on the eye will 
cause them ; they may arise also from a particular state of the arteries 
which supply the optic nerve, and thus at each pulsation of the heart a 
flash of light is seen. This morbid sensibility of the retina, which, under 
such circumstances, appears to be itself the source of light, is very often a 



AMAUROSIS. 587 

symptom which ushers in the extinction of the visual power. It is a very 
general remark, that hypersensibility of an organ is but too often the pre- 
lude to total loss of its functions. Thus we frequently have a morbidly 
sensitive state of the eye before it becomes incurably amaurotic, a morbid 
sensibility of the ear, ushering in loss of hearing, and unnatural excite- 
ment of the sense of touch preceding paralysis. But in this case we have 
not only an irritable condition of the retina, but also an affection of the 
pupil ; the iris is sluggish in its motions, and this symptom occurring at 
this particular period, combined with the vertigo, luminous hallucinations, 
and gradual but steady progress of the disease, give us some reasons to 
apprehend that it will end in complete amaurosis. Seeing, however, that 
the symptoms have originated in a congested state of the brain, it is our 
duty, as far as possible, to check its progress. This is to be done by 
cupping over the nape of the neck, leeching the temples and behind the 
ears, and acting on the bowels by brisk purgatives. With the same view 
I intend to insert a seton in the nape of his neck, and to administer the 
nitrate of silver internally, combined with a stnall quantity of aloes, a 
remedy which is possessed of some valuable properties in the treatment 
of chronic congestion of the brain, whether tending to produce amaurosis 
or headache. 

With respect to the causes of amaurosis, I may observe, that they depend 
either on disease of the brain, as congestion, inflammation, the presence 
of tumours of various kinds, or on injuries of the retina itself, or of the 
supra and infra orbital branches of the fifth nerve, or on affections of the 
alimentary canal. All these matters, however, have been so well detailed 
in different articles on amaurosis, to which I refer you, that I shall pass 
over them at present, and close my notice of this case with a few desultory 
remarks. I believe I mentioned in a former lecture, that I had seen a 
very curious case of amaurosis, in which the cause of the disease seemed 
to be connected with an impression made by cold on the facial branches ot 
the fifth nerve. I have already taught the class, that paralysis of any part 
of the body may arise from an oppression made not only on its own nerves, 
but also on the peripheral extremities of the nerves of another and even 
a distant part. I have also remarked that the fifth nerve is connected 
with the nerves of all the senses, but in particular with the optic, and 
hence we can explain why injuries of its supra and infra-orbital branches 
may bring on amaurosis. In the case to which I refer, the patient was 
exposed, while travelling outside on a stage-coach, to a keen north- 
easterly wind, and, when he arrived in Dublin, his lips were very much 
chopped, and the skin of his face bore evident marks of the cold, and 
drying powers of the wind. Soon afterwards, he began to complain of 
dimness of vision, and a thin gauze veil seemed to be extended between 
him and every object he looked at. After five or six days, when he 
applied to me, I found a considerable degree of amaurosis present, and at 
the distance of a few feet he was unable to recognise the countenance of 
a friend. He had no headache, vertigo, or tinnitus aurium ; in fact, 
nothing to indicate cerebral congestion, and his appetite was good, sleep 
undisturbed, bowels regular. He had never thought himself, nor did a 
medical gentleman, to whom he had applied, ever suspect, that the 
impression of cold on the face had produced the amaurosis, and he said 
that he had been advised to get himself leeched and cupped over the 
back of the neck. On examining into the cause of his disease, and having 



588 CLINICAL MEDICINE. 

found that he had been exposed to severe cold, it occurred to me that the 
amaurosis might be connected with the impression made by cold on the 
superficial branches of the fifth nerve, and, on more accurate investigation, 
I found that there were some grounds for this opinion. I was further 
confirmed in this view of the subject by the details of a case communi- 
cated to me by my friend, Dr. Montgomery, in which the patient evi- 
dently got paralysis of the portio dura from exposure of one side of the 
face to cold. Of course this paralysis was attended with distortion of 
countenance, in consequence of many of the muscles of the face. depending 
on the portio dura for their supply of nervous energy. But what was 
particularly remarkable in this case, was, that vision on the affected side 
of the face became dim and indistinct. Now, can this be explained? 
Yes, very easily. You all know that the branches of the portio dura have 
an extensive communication with the supra and infra orbital branches of 
the fifth. Now, the paralysis which commenced in the portio dura grad- 
ually extended to the branches of the fifth, and through them to the optic 
nerve, with which the fifth is intimately connected, and hence it was 
the retina became finally deranged in its function, and dimness was 
produced. 

There is one circumstance more to which, as I am on the subject of 
amaurosis, I shall briefly call your attention. You will recollect the case 
of a boy whom we have had very recently under treatment for amaurosis, 
and may perhaps remember that one of the remarkable points in his case 
was this : — when he looked straight forward he did not see any thing in 
the direction to which his eyes were turned, but he could see the objects 
that were considerably below, or to either side of, the axis of vision. 
There are two or three circumstances under which a person cannot see 
an object by looking directly at it, and I wish to state these circumstances. 
In the first place, it may happen that an opaque spot may be situated on 
the centre of the cornea and directly in the axis of vision, as we some- 
times see in cases of scrofulous ulceration, followed by permanent opacity 
of the cornea. Now, in this case it is plain that the person cannot see 
objects placed directly before him and in the axis of vision. The second 
case is one where the patient cannot see objects directly before him, but 
can distinguish them tolerably well at a certain angle of obliquity, the 
cornea being perfectly clear and uninjured in its texture. Now, this may 
arise from an opacity of the lens, limited to its centre, and not generally 
diffused through its substance. The lens is a compound body, the struc- 
ture of which was, until very lately, but little known. When the lens or 
its capsule is affected with opacity, this opacity is not always equally 
diffused, but sometimes occupies the central portions of these organs, while 
the circumferential portions retain their transparency. Hence, when a 
person under such circumstances wishes to see an object, it is necessary 
that the rays of light should fall obliquely in order to reach the retina. 
A third case is, where, although the cornea and crystalline lens are in the 
natural state, still the patient sees objects a little removed from the axis 
of vision much better than those which are in it, as in the case to which 
I have just alluded, where the patient could scarcely distinguish any ob- 
ject placed directly before him, but could see tolerably well objects at 
either side of, or below 7 , the direct line. The reason of this appears to 
be, that when a person so circumstanced looks directly at an object, the 
picture of the object falls on a part of the retina not obedient to the sti- 



AMAUROSIS. 589 

mulus of light. In the process of ordinary vision the parts around (he 
axis, and corresponding to the field of vision, have the picture of tlie ob- 
ject looked at, painted on them, and vividly and strongly illuminated. 
The central portion of the retina bears on it the picture of the object 
which the mind attends to, for it is surprising how indistinct and how 
little attended to, any object seen obliquely is. Now, where disease has 
rendered this central portion of the retina insensible to light, then the at- 
tention is immediately turned, with a greater degree of intensity, to the 
sensations derived from the surrounding portions, and the patient is ena- 
bled, so long as this portion retains its sensibility, to enjoy the sight of 
objects placed obliquely and not in the axis of vision. Even in healthy 
eyes the non-central portions of the retina may be rendered available in 
particular cases. This has been proved by Brewster, Herschel, and others. 
In looking, for instance, at a star of the smallest magnitude, it vanishes 
from the sight and is lost when looked at directly, but, if you turn a little 
from it, it will still catch the eye and be visible, because the image of the 
star will now fall on a part of the retina which is generally in darkness, 
and which is more sensible from being unaccustomed to the glare of light. 
Hence in many cases of amaurosis it is not unusual to find that the patient 
retains the power of vision so far as regards objects placed at an oblique 
angle with the axis of the eye after direct vision has been all but extin- 
guished. This is all I have to say at present with respect to amaurosis. 

As there is no other case presenting peculiarities to which I might call 
your attention, I shall beg leave to occupy your time for the remaining 
part of our lecture hour with a detail of the circumstances under which I 
have been led to employ the acetate of lead in Asiatic cholera, and to 
communicate briefly the mode of its administration and the results which 
attended its use. You are aware that during this epidemic, which com- 
menced its fearful career in Dublin in the spring of 1832, the modes of 
treatment principally relied on were, bleeding in violent spasmodic cases, 
emetics of ipecacuanha and mustard, the application of heat externally, 
and internally stimulants, but above all, calomel, not in small but in large 
and frequently-repeated doses, either alone or combined with opium. I 
need not tell you that the mercurial treatment came to us sanctioned by 
high authority : it was a remedy to which the experience of Indian prac- 
titioners had given a high character, but in our hands, I must say, it 
proved of very little value. Be this as it may, I must say that I had rea- 
son to be dissatisfied with this mode of treatment ; I had tried it myself, 
and had seen it tried in every way which ingenuity or experience could 
suggest, but I had seen it fail almost in every instance. 

About the middle of last summer the epidemic, began to spread fearfully 
among those who had hitherto been exempt from its attacks ; many per- 
sons in respectable life were seized, and my private practice afforded 
numerous opportunities of becoming practically acquainted with the dis- 
ease. In several cases to which I was called in, the malady had not ad- 
vanced to the stage of collapse, the symptoms of cholera, properly so 
called, had merely commenced, the intensity of the disease was still far 
away, and a fair chance was afforded for the operation of therapeutic 
agents. In most instances, I tried calomel and all the ordinary remedies 
with profitless results ; my treatment proved too often ineffectual ; and 
some persons, whose lives I highly valued, perished in spite of all my 
efforts, leaving me grieved for their loss, and mortified by my own want 



590 CLINICAL MEDICINE. 

of success. I found that I could no longer place any confidence in calo- 
mel, and determined, in my own mind, to give up a remedy which had 
so signally failed ; it was, however, a question of deep anxiety to me what 
I should select instead, or to what article in the Materia Medica I should 
have recourse, where so many had proved utterly valueless. 

About this period I happened to be called on to attend a case of obsti- 
nate diarrhoea with my friend Dr. Hunt. The case was an extremely 
harassing one, and had resisted all the ordinary remedies. I advised the 
use of acetate of lead and opium in full doses ; this was given, and I had 
the satisfaction of finding that the diarrhoea soon yielded. Before this 
period I had received a letter from that able practitioner and excellent 
man, Dr. Bardsley, of Manchester, directing my attention to the use of 
acetate of lead in large doses in that form of diarrhoea which occurs to- 
wards the termination of long fevers, that is to say, the diarrhoea which 
precedes and accompanies inflammation of the glands of the small intes- 
tines. I had subsequently, at Sir P. Dun's Hospital, several opportunities 
of witnessing the truth of Dr. Bardsley's remarks. I saw that, in many 
cases during the course of fever, where the patient was low and pros- 
trated, symptoms of intestinal congestion came on, followed by diarrhoea, 
which many persons thought would end in ulceration of the glands of 
Peyer ; and I found that in such cases the acetate of lead was the only 
remedy that could be relied on. I observed, too, that, contrary to the 
prevailing opinion on the subject, it could be given in large doses with 
perfect safety. You are aware that Dr. Bardsley has shown that it may 
be given to children in very considerable doses without any bad effects, 
and that in adults he has pushed this remedy to the extent of twenty or 
thirty grains in the day, without any unfavourable consequences. 

With these impressions I came to the resolution of trying the acetate of 
lead in the next case of cholera which offered a chance of deriving benefit 
from any kind of treatment. Jt is known that there are some cases in 
which the disease at once assumes so frightful a malignity, that the patient 
is lost from the very moment of his seizure. This hopeless and intrac- 
table malignity is not peculiar to cholera ; it is seen in fever, scarlatina, 
croup, measles, and hydrocephalus ; in fact, there are certain forms of all 
diseases in which the best-directed efforts of medical skill not only fail in 
curing the disease, but even in* retarding its progress. But there are 
cases of cholera where the patient is not struck down at once, where the 
disease is not developed at once in all its awful intensity, and where time, 
brief though the space may be, is allowed for the play of therapeutic 
agencies. It is in such cases the acetate of lead may be given with some 
prospect of success, and it is by such cases alone, and not by those which 
are necessarily fatal ab initio, that its value is to be tested. 

Before we proceed further, I may observe, that the principle on which 
the calomel treatment was employed in cholera arose from almost constantly 
observing that there was a total deficiency of bile in the stools. Soon 
after the supervention of an attack, the alvine discharges were observed 
to be white and without the slightest tinge of bile ; and on this very re- 
markable symptom practitioners dwell almost exclusively, thinking that 
the patient's only chance lay in restoring the secretion of the liver. Now 
it is obvious that the absence of bile in the stools is no more a cause of 
the disease than is the deficiency of urea in the kidneys or of serum in the 
blood. Viewing the disease in this light, it would be just as reasonable 



ACETATE OF LEAD AND OPIUM IN CHOLERA. 591 

to give a diuretic to restore the secretion of the kidneys, as to give calo- 
mel to produce, a flow of bile. The liver ceases to secrete, not only in 
consequence of the injury done to its vitality by the proximate cause of 
cholera, whatever that may be, but also from a mechanical cause, namely, 
from a diminution in its supply of blood. It may appear strange that 
when the same given number of vessels go to the liver and come from 
it at all times, that the quantity of blood circulating in it should be greater 
at one time than another. I have not time at present to enter fully into 
this subject; but it is a fact admitting of sufficient proof, that the quan- 
tity of blood circulating in any organ is very much modified by the state 
of its capillaries. The quantity of blood also which goes to a gland varies 
according to the peculiar state of that gland, being greater during its 
period of active secretion than when it is at rest. But in a case of cho- 
lera, where the capillary vessels of the intestinal canal from the stomach 
and the rectum are actively engaged in taking up the serum from the 
whole mass of blood, and pouring it into the cavity of the digestive tube, 
there is an enormous drainage from the system, and there must be, con- 
sequently, a deficiency of blood somewhere. Now it would appear that 
a quantity of blood, sufficient for the purposes of secretion, is abstracted, 
not only from the biliary, but also from the urinary system ; and hence it 
appears just as reasonable to give diuretics to restore the urinary secre- 
tion, as to give calomel to excite the secretion of the liver. It would be, 
a priori, as original a mode of treatment, and be equally as successful. 
I have therefore no hesitation in saying, that the calomel treatment has no 
claim to merit on the ground of theory, and, as far as I have observed of it in 
this country, it seems to be of no practical value in the treatment of cholera. 
With regard to the quantity of acetate of lead which may be given in 
this disease, and the mode of administering it, a few words are neces- 
sary. I have already stated, that when I first tried it, I prescribed it in 
large doses, fortified by the authority of Dr. Bardsley, and by my own 
experience of its utility in many cases of diarrhoea. It appears, that 
before I recommended the acetate of lead, it had been used at the Cho- 
lera Hospital in Grangegorman-lane. Of this I was not aware, until a 
book was subsequently published by Dr. Cranfield, which I afterwards 
reviewed in the Dublin Medical Journal, and I feel that on that occasion 
I did fair and impartial justice to its merits. I certainly did not know 
that the acetate of lead had been given at the Grangegorman Hospital ; 
for, in the very able report of cholera, as observed at that institution, 
published by one of its officers, Mr. M'Coy, the treatment relied upon 
appears to have been the mercurial, and not a word was said of acetate 
of lead. It had certainly been used there by one physician ; but it was 
given in smaller doses, insufficient to produce decided effects, and no 
stress had been laid on its value as a remedy in cholera by the practi- 
tioners attached to the hospital. Be this as it may, acetate of lead was 
not known to the medical men of Dublin, and to the practising apotheca- 
ries, before I recommended it. It had been frequently employed in the 
form of injection by them ; but no one had given it in large doses by the 
mouth, or introduced it to the particular notice of the profession. I be- 
lieve I can fairly claim the merit, such as it is, of being the first to give 
it in large and effectual doses. The mode in which I prescribed was 
this : — a scruple of the acetate of lead, combined with a grain of opium, 
was divided into twelve pills, and of these, one was given every half- 



592 CLINICAL MEDICINE. 

hour, until the rice-water discharges from the stomach and rectum began 
to diminish. In all cases where medicine promised any chance of relief, 
this remedy was attended with the very best effects. It gradually checked 
the serous discharges from the bowels, and stopped the vomiting. I need 
not say of what importance this is: as long as these exhausting discharges 
continue, as long as the serum of the entire body continues to be drained 
off by the intestinal exhalants, what hope can we entertain ? What benefit 
can be expected from calomel and stimulants, when every function of the 
digestive mucous membrane seems to be totally extinguished,. except that 
of exhalation, and while profuse discharges, occurring every five or ten 
minutes, are reducing the patient to a state of alarming prostration ? 
Knowing the inevitable fatality of all cases where these discharges went 
on unchecked, I was happy in having discovered a remedy which seemed 
to possess more power in arresting them than any yet devised, and this 
impression was confirmed by the results of subsequent experience. That 
the acetate of lead will succeed where all other astringents fail, was 
proved by the case of Mr. Parr, of this hospital. Having got an attack 
of threatening diarrhoea, at a time when cholera was prevailing in Dublin, 
this gentleman used various kinds of astringents, and took so large a 
quantity of opiates, that he became quite narcotized, but without any relief 
to his symptoms. When I saw him he was as bad as ever, and was be- 
ginning to exhibit appearances of collapse. I advised the use of pills, 
composed of acetate of lead and opium, in the proportions already men- 
tioned, and had the satisfaction of rinding that before night the diarrhoea 
had ceased. The pills are to be used one every half-hour while the diar- 
rhoea remains unchecked, but as it begins to diminish, the intervals be- 
tween each pill may be prolonged, and in this way the patient may be 
gradually prepared for leaving off the remedy altogether. I have fre- 
quently given in this way as much as forty grains of acetate of lead in 
twenty-four hours, with great advantage to the patient, and without any 
bad consequences ensuing. 

It is unnecessary for me to say any more on this subject ; if I chose to 
mention names, I could bring forward the names of many medical men 
in Dublin, whose lives, I am happy to state, were saved by the use of 
this remedy. I may, however, observe, that this mode of treatment has 
now become universal here, and that it has almost completely superseded 
the use of calomel and opium. I will confess that this fact is a source of 
high gratification to me, and I point also with pleasure to the fact, that 
since it became extensively known (as it did during the last invasion of 
the epidemic), the profession has gained more credit than before, and the 
number of cures has been proportionally greater. 

I have referred to this subject also for another reason. I feel it a duty 
which I owe myself, to defend myself against a series of attacks which 
were made on me, and to vindicate my claims, not to having been the 
first to administer acetate of lead, for it had been given previously by 
Dupuytren, and at the Grangegorman Cholera Hospital, but to having 
been the first to prescribe it in large and sufficient doses, to render it an 
available and useful remedy, and to introduce it to the general notice of 
the profession. The credit to which I lay claim, rests solely on these 
grounds. 1 have been attacked on more than one occasion in the public 
papers, and gentlemen signing themselves Honestas, Candidus, and Verax 
(per antiphrasin, I suppose, for they have shown neither honesty, candour, 



REMARKABLE MOBILITY OF THE STERNUM. 593 

nor truth), have attempted to rob rue of the merit of what they sneering! v 
called the lead treatment. I have thought it necessary to say so much in 
the way of explanation, lest any of my friends or pupils should misinter- 
pret my silence.* 

The following case of remarkable mobility of the sternum was observed 
by Dr. Stokes and myself. A medical student, nineteen years of age, and 
of a sanguineous temperament, who had often been attacked by violent 
pectoral inflammation, particularly a few years ago, but who had since 
become comparatively healthy and robust, applied to me for advice con- 
cerning a pain in his chest. This happened after lecture in Sir P. Dun's 
Hospital, in the presence of several of the students and Dr. Law, who saw 
with astonishment this young man open his shirt, and with his hand push 
the sternum deep inwards towards the spine, so as to convert the anterior 
part of the chest into an extensive and by no means shallow cavity, at the 
bottom of which was the sternum. The rapidity with which this was ef- 
fected, and the unnatural appearance the chest then presented, excited a most 
disagreeable feeling of alarm in the minds of the spectators ; for we could 
not avoid dreading that he was inflicting on himself some serious injury. 

The portion of the chest which yielded in this singular manner to pres- 
sure, comprised the sternum from within two inches of its superior edge, 
and seemed below this point to be limited laterally by the lines answering 
to the junctions of the cartilaginous with the osseous portions of the ribs, 
so that the whole space capable of being pressed inwards was nearly trian- 
gular in shape, and was very extensive. The sternum was so tender to 
the touch, that in applying the pressure, he was obliged to press at some 
distance at each side of this bone. When the pressure was carried to the 
farthest point, the sternum was pushed in, as nearly as we could guess, 
about two inches, and the action of the heart, as well as that of the subja- 
cent lung, appeared to be notably diminished, and, in consequence of this, 
the pulse was weakened. This young man was subject not only to con- 
stant pain in the sternum, but likewise to frequently-recurring violent pal- 
pitations of the heart. His chest was sufficiently ample and well formed, 
but he had lately become round-shouldered, in consequence of his seeking 
relief from pain by stooping forward. No other portion of his osseous sys- 
tem exhibited the least trace of softening. The only affection which I 
can call to mind the least resembling this, is the softening which some- 
times affects the female pelvis, giving rise to great distortion, and which 
softening is accompanied, during the months or even years of its forma- 
tion, by severe pelvic pains. 

* While these pages were passing through the press, I received the following gratifying 
note from my friend Surgeon Auehinleck, of Dominick Street, which I have much pleasure in 
laying before the reader : — 

" Dominick Street, September 6, 1842. 

" Dkar Graves, — [ have received lately a letter from my brother (Dr. Claudius Auehin- 
leck), at present quartered at French Rocks, Seringapatam, in which he mentions that cholera 
had broken out among the native troops quartered there, and that he had recourse to the use 
of calomel and opium in large doses, to arrest its frightful progress, but that he found it totally 
inadequate. He therefore laid it aside, and adopted in its place the administration of the 
acetate of lead and opium, as recommended by you, and was much gratified by the favourable 
results, the mortality being greatly reduced, and finally, on the change of the monsoon, the 
disease itself disappearing. He requested that I should mention this fact to you, which I do 
with much pleasure. Very truly yours, 

» VVM. AUCHINLECK. 

" Doctor Graves, Merrion Square." 

39 



594 CLINICAL MEDICINE. 



LECTURE XLV. 

Case of phlebitis — Remarks on the symptoms and treatment of this disease — Pathology of 
phlegmasia dolens — Its treatment — Case of cancrum oris — Fatal termination — Remedies 
employed — Case of ague cake — Observations on the different varieties of ague — True ague, 
or intermitting fever — Ague produced by inflammation of internal organs — Nervous ague — 
Hysterical ague — Treatment of ague cake. 

Among the 'cases at present under treatment in our wards, that of Mary 
M'Quade particularly demands your attention. This poor woman was ad- 
mitted a few days since labouring under an attack of fever, accompanied 
by considerable prostration, anxiety, and restlessness; in addition to these 
symptoms, she has a local affection of a very important nature: the right 
leg, as far as the knee, is swelled to twice its natural size, and a large ery- 
sipelatous blotch occupies the fore part of the foot, extending over the 
ankles on each side. The thigh also is increased in size as far as its upper 
third, so that the tumefaction embraces more than two-thirds of the whole 
extremity. There is a considerable degree of tension present, and the limb, 
particularly along the internal surface as the leg, is extremely tender, the 
soreness being so great over the course of the veins and lymphatics, that 
vShe could not bear the slightest touch. 

Here we had a swelling of the lower extremity depending on an inflam- 
matory condition of the part, and the question is, in what tissue did it com- 
mence, and what are its characteristic features? Before we discuss this 
question, it may be proper to observe here that the disease had its origin 
from cold. When a patient is exposed to cold under unfavourable cir- 
cumstances, local inflammation is generally the consequence, and it de- 
pends on a variety of causes of what description the inflammation will be, 
and on what particular part it will fall. Where the lower extremities are 
the parts chiefly exposed, inflammation of the cellular membrane of the 
leg is apt to ensue, or it may attack the veins, as in the case before us, 
constituting phlebitis, or the lymphatics may be primarily and almost ex- 
clusively engaged. In a few cases inflammation attacks the arteries of the 
limb, as in a case which has been published by Dr. Stokes and myself in 
the Dublin Hospital Report, where a person, after exposure of the lower 
extremities to cold, got an attack of arteritis, terminating in mortification 
of the limb and death. Exposure of the lower extremities to cold, gives 
rise to phlebitis much oftener than to arteritis. Dr. Stokes and I have 
published a striking case where inflammation of the veins of the leg was 
produced by this cause. You will find this case referred to by Dr. Lee, 
in the excellent article, Phlegmasia Dolens, in the Cyclopaedia of Practical 
Medicine. You perceive, then, that painful swelling of the lower extre- 
mities originating in cold, may consist either in the whole cellular mem- 
brane being engaged, or it may arise from inflammation of the lymphatics 
of the veins, or of the arteries. Now when inflammation attacks in the 
first instance the subcutaneous tissue of the lower extremities, it frequently 
in its progress involves the lymphatic and venous tissues, the arterial very 
seldom, for the arteries lie deep, and have no connection with the subcu- 
taneous cellular membrane. There is, however, nothing more common 
than that inflammation commencing in this way should terminate in phle- 



PHLEBITIS — PHLEGMASIA DOLENS. 595 

bitis, and disease of the lymphatics. This appears to be the nature of 
phlegmasia dolens, that peculiar inflammation which generally attacks one, 
and seldom both, of the lower extremities, which is most commonly ob- 
served in females, and which is characterized by swelling not pitting on 
pressure, by excessive cutaneous tenderness, and by a remarkable white- 
ness of the skin of the affected limb, accompanied by increased heat, and 
more or less lesion of the locomotive function. These are the principal 
symptoms which characterize phlegmasia dolens. The inflammatory con- 
dition of the limb causes an exudation of fluid into the cellular membrane, 
consisting partly of serum and partly of lymph; this produces swelling 
which is of a firm and rather unyielding character, not pitting on pressure 
like that which results from anasarca. After some time the inflammation 
extends to the neighbouring tissues, and attacks the veins and lymphatics, 
a circumstance which has led many persons, among others Dr. Lee, to 
believe that phlegmasia dolens arises primarily from phlebitis. This, how- 
ever, is not borne out by the fact, nor is it true that it consists in inflam- 
mation of the lymphatics, as others have suggested ; it may engage both 
the lymphatic and venous tissues, but it differs in many points from pure 
phlebitis, or true inflammation of the lymphatics. 

In the case before us it would appear that the inflammation commenced 
primarily in the veins, and by a careful examination you will be able to 
discover some essential points of difference between the disease and 
phlegmasia dolens. There is a good deal of soreness present in this case, 
but the exquisite neuralgic tenderness of phlegmasia dolens is wanting. 
Again, the shining appearance of phlegmasia dolens is absent, and the co- 
lour differs greatly from the dead whiteness observed in that disease. The 
tenderness also is here more localized, being chiefly complained of on the 
inside of the limb, and along the course of the veins and lymphatics. On 
the other hand, it may be observed that these affections have many symp- 
toms in common, and you may have remarked that here, as in phlegmasia 
dolens, the locomotive power of the limb is considerably diminished. 
This, however, has been remedied, to a certain extent, by the curative 
means employed, and the patient is now able to raise up the whole limb, 
and bend the leg on the thigh. Now, whence arises this loss of power 
so often witnessed in cases of phlegmasia dolens, and phlebitis, and in- 
flammation of the subcutaneous cellular tissue of the lower extremities ? I 
am inclined to think it depends on a morbid impression made on the 
ultimate ramifications of the sentient nerves, which is propagated along 
the larger trunk to the spinal cord, and from thence by a reflex course is 
brought to bear and react on the muscular nerves of the limb. In my 
remarks on paraplegia, I have spoken of this matter at large, and given 
several instances of loss of power in a limb, produced by impressions 
made on the extremities of its cutaneous nerves ; and such appears to be 
the lesion of the locomotive power observed so frequently in cases of 
phlebitis and phlegmasia dolens. In many cases of paralysis, we find the 
first stage of the disease attended with an increased sensibility of the 
nerves of the part affected, tending to show that the primary source of 
the disease consists in an impression made on the sentient extremities of 
the nerves ; and there is nothing more common in such cases than to find 
the loss of the motor power accompanied by deranged sensation. In 
phlegmasia dolens and phlebitis, we have great cutaneous tenderness, and 
this is very rapidly followed by more or less diminution of the muscular 
power of the limb. 



596 CLINICAL MEDICINE. 

I shall now refer briefly to the curative means employed in this case, 
observing that it has this in common with many cases of phlegmasia 
dolens, viz., the inflammation has engaged in succession the cellular 
membrane, veins, and lymphatics. When the lymphatics are attacked 
with inflammation, they become swelled, and have a knotty cord-like 
feel, and this condition is most commonly attended with the appearance 
of erysipelatous patches on various parts of the limb, over the place 
where a number of lymphatics are simultaneously engaged. This appears 
to be the case in the present instance, and it explains the occurrence of 
the erysipelatous blush which covers the instep and ankle. I need not 
tell you that the appearance of erysipelas over any part of a limb so cir- 
cumstanced, strongly demands our attention, as it might be an indication 
of the seat of an injury which may have given rise to the disease. In this 
case, however, it was the product of the disease, and had no connection 
with its origin. The treatment of a case of this description cannot be 
conducted on strict antiphlogistic principles. The fever which accompa- 
nies venous inflammation is of a low typhoid character, and prostration 
sets in at a very early period. The intimate connection of the venous 
system with the whole economy, the peculiar character of the inflamma- 
tion affecting the venous tissue, and the rapid prostration of strength 
which ensues, are all circumstances which contra-indicate general deple- 
tion. On the other hand, the best effects have been obtained by active 
local bleeding, and this appears to be so much the more necessary in 
cases of phlebitis, as the inflammation is apt to run very quickly into the 
suppurative stage. I therefore ordered forty leeches to be applied along 
the inside of the affected limb, directing the nurse to encourage the bleed- 
ing by warm fomentations. In addition to this, two ounces of mercurial 
ointment, combined with two drachms of the extract of belladonna, were 
spread on large pieces of lint, and applied over the limb after the leech- 
bites had ceased to bleed. That mercurial ointment thus applied has a 
tendency to subdue inflammation of a low erysipelatous character, has 
been shown by Mr. M'Dowel in an excellent paper published in an early 
number of the Dublin Medical Journal. To this we added the extract of 
belladonna, because the local inflammation was attended with hypersensi- 
bility of the limb, a condition over which belladonna is known to possess 
a remarkable influence. Dr. Lee, I should observe, does not appear 
aware of the great utility of narcotics in the painful swelling of the extre- 
mities after fever, or in true phlegmasia dolens. In both these diseases, 
together with active local depletion by means of the frequent application 
of leeches, we should employ anodyne ointments, and, above all, large 
doses of opium internally. Some patients in phlegmasia dolens, if the 
bowels be regulated, will bear and derive benefit from four, five, or 
even six grains of opium in the day ; I speak of the second stage of the 
disease. The same observation applies with regard to wine, and to sul- 
phate of quinine. It is obvious that phlegmasia dolens consists of some- 
thing besides mere inflammation ; the pain is altogether different from 
that attending ordinary phlegmasia ; it resembles more a general neuralgia 
of the extremities of the subcutaneous nerves. The internal treatment 
consisted in giving a few grains of hydrarg. cum creta three times a-day, 
to keep up a free state of the bowels, and with a view of gently affecting 
the system. These means are very likely to be attended with success. 
The woman at present is much better, and the inflammation is sensibly 



CANCRUM ORIS. 597 

declining. I shall not, however, anticipate the result, and for the present 
shall only call your attention to the case. 

You may perhaps ask me to account for the great tumefaction of the 
limb observed in this case. It has been supposed by some persons that 
the whole swelling depends on the obstruction of the veins ; but if inflam- 
mation was entirely limited to the veins, the swelling could not be so 
extensive. It is true that if you produce artificial obstruction of any of 
the great veins, by placing a ligature on it, you cause, for the time, very 
considerable edema of the limb. The obstruction to the passage of 
blood through an inflamed vein will necessarily give rise to a certain de- 
gree of swelling, but I am inclined to think that this is not the only source 
of the tumefaction ; it would appear that in addition to phlebitis we have 
the inflammatory process communicated to the neighbouring parts ; the 
cellular tissue and probably the lymphatics become engaged, there is a 
copious effusion of serum and lymph, and to this the general increase in 
size of the limb is to be chiefly attributed. 

With respect to the termination of phlebitis, I may remark that it gene- 
rally ends in adhesion of the sides of the vein, and obliteration of its 
cavity, so that when the patient recovers, the affected vein feels like a 
piece of whip-cord lying under the skin. We had some patients here 
who had obliteration of this kind, and in one of them who died after- 
wards of fever, I found some of the smaller subcutaneous veins had be- 
come totally impervious through their whole extent, and resembled hard 
cords. This is all I have at present to say with respect to phlebitis, ob- 
serving that the diseases which are most analogous to it are phlegmasia 
dolens, and a particular morbid enlargement of the lower extremity, 
which has been described by Dr. Tweedie, and by Dr. Stokes and myself, 
in the Meath Hospital Reports. 

A child about four or five years old, who has been for some time in the 
fever ward, has been recently attacked with a very formidable disease, 
cancrum oris. Like most patients labouring under this malady, she had 
been previously debilitated by the occurrence of fever, for a child in good 
health seldom, indeed I may say never, gets an attack of this kind. A 
preceding febrile condition of the system, and a depraved habit of body, 
must have existed in every case where cancrum oris occurs. The disease 
itself is nothing more than mere local inflammation setting in under unfa- 
vourable circumstances, and during a morbid state of the system, and 
hence the local inflammation rapidly assumes the gangrenous character. 
In children, many forms of general disease are apt to bring on a state of 
the system in which inflammation of any part has a strong tendency to 
run into gangrene, and this is to be borne in mind with reference to 
the present case, for cancrum oris has nothing peculiar in it except its 
situation. 

It is not my intention at present to enter into any particular description 
of this disease. It has been well described by many surgical writers, and 
you will find a very valuable essay on the subject published by Dr. 
Cuming in the fourth volume of the Dublin Hospital Reports. There is 
also a very excellent article on cancrum oris in Forbes's Cyclopaedia of 
Practical Medicine, to which I beg leave to refer you. It may, however, 
be necessary to allude briefly to some points connected with its treatment. 
In the first place, I may observe, with reference to the general principles 
of treatment, that you should not be misled by the name of the disease, 



598 CLINICAL MEDICINE. 

or think that because there is a gangrenous condition present, you should 
rely exclusively on detergent and antiseptic remedies. This is a common 
but pernicious error — it is the error of prescribing for names and not 
diseases, the easy but dangerous practice of unreflecting empiricism, by 
which the reputation of medicine has been so often damaged. He who 
commences the treatment of cancrum oris with the internal and external 
use of antiseptics, is acting on false principles ; his practice may have the 
sanction of time, but it has not the support of observation and experience. 
In the early stage of the disease, when the cheek is of a deep red colour, 
tense, prominent, and shining, I do not know of any means which tend 
so directly to diminish the amount of inflammation, and check the progress 
of gangrene, as the application of leeches, few in number, but frequently 
repeated. This is the mode of treatment which I have found to be most 
effectual, and which, from my experience of the disease, I can recommend 
as the most likely to prove beneficial, when, unfortunately, the ordinary 
resources of medicine are too often ineffectual. 

With respect to internal remedies, Dr. Cuming lays great stress on the 
utility and value of purgative medicines. They may be certainly neces- 
sary, and as the little patients very often swallow the sanious discharge 
from the ulcer, more or less derangement of the intestinal canal must 
accompany the disease. But along with purgatives I would strongly 
recommend the use of sulphate of quinine, either in the form of enema, 
or, if the child can be got to swallow it, made up into a syrup, and its 
solution favoured by the addition of a little sulphuric acid. With regard 
to the external applications, you have a choice of many remedies, each of 
which you will find recommended by authors, but none of which can be 
exclusively relied on in any case. The balsam of Peru with castor oil 
forms a good application, or you may blend it with honey, as we did in 
this case — one ounce of the balsam to two ounces of honey. You may 
also employ washes composed of solutions of nitric or muriatic acids, or 
of the chlorides of soda or lime. 

In the present instance the sore has, in spite of all our efforts, eat its 
way from the internal to the external surface of the cheek. On Saturday, 
the centre of the cheek was characterized by the appearance of a bluish- 
black spot, indicating the occurrence of sphacelus. In the meantime it was 
curious to observe how little constitutional disturbance was yet produced ; 
the child, notwithstanding the manifest existence of extensive sphacela- 
tion of the cheek, continued for several days to have a tolerable appetite, 
and to sleep well, being nearly free from fever, and complaining but 
little ; as the mortification progressed, destroying rapidly the external 
parts of the cheek, &c, matters soon altered, and the poor little patient 
sunk exhausted and suffering. 

Let us now direct your attention to the case of a sailor who has recently 
been discharged. This boy was one of the crew of a vessel which re- 
turned lately from the West Indies, and was exposed to great hardship 
during his voyage. Boys in his situation suffer a great deal of fatigue 
and rough treatment ; they are the drudges of all on board, and it is impos- 
sible to conceive what privations they endure. When the vessels arrive 
in unhealthy climates they are generally the first who fall victims to the pre- 
vailing malady, and such was the case of this lad, who got yellow fever 
immediately after his arrival at the West Indies. From this he recovered, 
but on his way home he was attacked with irregular intermittent, which 



AGUE CAKE. 599 

lasted for a considerable time. He had no treatment, and the disease 
subsided spontaneously, leaving him extremely weak and emaciated. He 
was, however, obliged to work as usual on his passage, and he arrived 
in Dublin about three weeks since, debilitated, thin, and with a counte- 
nance expressive of long-continued suffering. He had on his admission 
that peculiar hue of skin which often follows tedious intermittents, and 
which those who have once seen will always recognise with facility. 
This colour is to be distinguished from the hue of light jaundice — it is 
what has been termed clay colour. In the present instance it was mixed 
with a faint tinge of jaundice, and on examining the stools we found that 
they contained scarcely any bile. He had no fever; his pulse was rather 
slow and regular ; he complained of lassitude ; his urine was deeply 
tinged with bile ; and his belly tumefied. On examining him, we found 
that the abdominal tumefaction did not depend on the presence of fluid 
in the peritoneum : it was produced by enlargement of the liver and 
spleen, intestinal congestion, and tympanitis. 

Here was a case of what has been vulgarly termed ague cake ; that 
species of congestion and enlargement of the liver and spleen which is 
apt to accompany the paroxysms of an intermittent, and in some cases to 
remain after the disease has subsided. You are aware that some persons, 
during the paroxysm of an intermittent, will complain of pain in the right 
hypochondrium, but more frequently in the left, and on examination the 
liver or spleen is found increased in size. If you take the trouble of 
reading the experiments which have been made with the view of illus- 
trating the functions of the liver and spleen, you will have a good idea of 
the facility with which enlargement of these organs, but particularly of 
the latter, may take place. The spleen undergoes very remarkable 
changes, even in its natural state, during the process of digestion, and 
there is a great difference between its size when an animal is lasting, and 
its size when an animal has taken food. Indeed, it is surprising how 
rapidly it will become filled with blood, and how quick the transition is 
from a state of collapse to a state of congestion. It is easy, therefore, to 
conceive how the spleen may, during the paroxysms of an intermittent, 
particularly in the cold or congestive stage, become manifestly enlarged. 
The increase of size, however, never occurs to such an extent in the 
liver ; unlike the spleen, its magnitude remains nearly the same, and its 
volume does not vary like that of the spleen with the time of day or the 
period of digestion. It is obvious, therefore, a priori, that the spleen 
should be more frequently the seat of congestion than the liver, and that 
its enlargement should be more distinct and palpable. But it is not in 
the liver or spleen alone that congestion occurs during an aguish paroxysm, 
it may take place in any organ ; and this, in a practical point of view, is 
worthy of being borne in mind. Thus, in a case which I attended, the 
patient got intermittent of a tertian type ; during each paroxysm he had 
some distress about the chest and slight cough, but these symptoms dis- 
appeared during the intervals. As the disease, however, went on, the 
fits of coughing and dyspnoea increased, and the sulphate of quinine failed 
in arresting the paroxysms. The pulmonary congestion became gradually 
more marked and permanent, and no longer disappeared during the 
intervals ; finally, inflammation of the lung took place, and the patient died 
with extensive hepatization. This happened about twelve years ago, 
when the old notion of connecting the cold stage of ague with debility 



600 CLINICAL MEDICINE. 

was universally prevalent, and before the practice of bleeding for the 
relief of visceral engorgement had been introduced. Subsequently, the 
practice of bleeding in the cold stage, as introduced by Dr. Mackintosh, 
was tried on an extensive scale in the Meath Hospital, and it is a practice 
which I can strongly recommend in those cases where there is recurring 
inflammation of some internal organ. It is not a mode of treatment appli- 
cable to all cases, and in mild cases unaccompanied by excessive con- 
gestion of any viscus, it is totally unnecessary ; but where an important 
organ is threatened, it is a valuable remedy, and has on some occasions 
cut short the paroxysms altogether, or rendered them much milder and 
more manageable. 

Sometimes ague is accompanied by symptoms of congestion and in- 
flammation of some internal organ during the paroxysms ; and yet, by 
giving sulphate of quinine, you will succeed in arresting the intermittent 
and the visceral disease at the same time. I recollect the case of a boy 
who was under treatment here for ague, and who, during the paroxysms, 
had severe bronchitis with dyspnoea. The cough did not leave him even 
during the intervals, but it was much milder ; I was, however, doubtful 
whether the case would admit of the exhibition of sulphate of quinine, 
from the violence of the pulmonary symptoms during the, fits. I deter- 
mined, after some time, to try the quinine, and I found that it stopped 
both the intermittent and the bronchitis. It is to be observed, however, 
that in this case the bronchitis was of a chronic character ; and I believe 
that in all cases of ague accompanied by visceral derangement, where 
quinine succeeds in curing the disease, the inflammation is either of a 
trifling description, or is one of a chronic nature. Where the visceral 
derangement is great, quinine will not succeed, and hence it is of great 
importance, in the treatment of ague, that you should carefully attend to 
the state of the internal organs. 

There are several forms of disease which simulate intermittent in a very 
remarkable manner; and, as this may lead to very dangerous errors, it is 
necessary on all occasions to make a strict inquiry into the origin and his- 
tory of the complaint. Some forms of hectic assume the intermittent cha- 
racter, and have been frequently mistaken for ordinary ague. Of this I 
had lately a very striking instance in the case of a lady, who came from 
the county of Limerick to consult me for what was stated to be an attack 
of irregular intermittent. She had been confined in August ; had been 
feverish after her accouchement — the consequence, she believed, of ex- 
posure to cold — and got a slight cough. This continued, but without 
any expectoration, for two or three weeks, and then she was attacked 
with fever of an intermittent character, and exhibiting a well-marked ter- 
tian type. She began to take quinine, but this aggravated the cough very 
much without having any effect on the paroxysms. Various other reme- 
dies were also tried, but their only effect was to render the paroxysms 
more frequent and irregular. The moment I saw her I was convinced 
that she was labouring under some visceral disease. I examined her 
chest, and found dulness under the right clavicle with tubercular crepitus. 
Her cough had been dry until she came to Dublin, but now it became 
suddenly moist, and a distinct gargouillement could be heard. The ap- 
parent intermittent was nothing more than phthisical hectic; and Dr. 
Stokes, who was also called in, came to the same conclusion. I recollect 
having observed something of the same kind in a case which I attended 



HYSTERICAL AGUE — TREATMENT OF AGUE CAKE. 601 

some time ago with Sir Henry Marsh. The patient had well-marked in- 
termittent, and we treated him for it ; but the sulphate of quinine, and 
the other remedies which we employed, had only the effect of converting 
the fever into remittent. On a sudden, the gentleman, without having 
made any complaint of pain in the side, or any thing indicative of de- 
rangement of the liver, became suddenly jaundiced, and sank rapidly. 
On dissection, we found seventeen or eighteen small circumscribed ab- 
scesses in the substance of the liver. The intermittent hectic here de- 
pended on interstitial inflammation of the liver — a disease which is gene- 
rally of a latent and incurable character. 

I need not refer here to certain forms of fever which accompany disease 
of the brain and of the urinary system, and which are remarkable for their 
intermittent character. There is, however, one form of anomalous inter- 
mittent, of which it may be necessary to say something : I allude to that 
species of ague which seems to be exclusively confined to females of a 
nervous habit — at least I have never met with it in any others. Persons 
of this description, after an accouchement or some acute disease, or in 
consequence of violent mental emotions, will sometimes get into a pecu- 
liar state of health, in which they are liable to recurring periodic attacks 
of fever. Some time since, Dr. Stokes called me to see a lady who, 
shortly after her confinement, had got an attack of well-marked tertian. 
She had, at the regular time, severe rigors, followed by acceleration of 
pulse, heat of skin, and profuse sweating. When the paroxysm was over, 
she felt tolerably well, but still there was much excitement of pulse, and 
the intermissions were any thing but perfect. Sulphate of quinine had 
been tried by the accoucheur in attendance, but had failed. On exam- 
ining the case, I found that the lady was of a decidedly nervous and hys- 
teric habit, and advised the use of nervous and antispasmodic medicines. 
A mixture containing musk, camphor, and ammoniated tincture of vale- 
rian, was prescribed, and the intermittent symptoms rapidly disappeared. 

But to return to the case of this boy. How are we to treat this ague 
cake ? The disease has not as yet proceeded so far as to produce ascites ; 
but if permitted to run on, it would soon cause effusion into the peritoneal 
cavity. In a case of this kind a great deal will depend on whether there 
is any fever present or not. If there is no remarkable excitement of pulse 
or heat of skin, general antiphlogistic means will be unnecessary, for any 
local tenderness or irritation can be relieved by local bleeding. In the 
case before us, there was a slight degree of tenderness, and we applied 
leeches once with benefit ; but we did not apply them over the abdomen 
— they were applied to the anus, because it is well known that leeches 
applied in this situation have a remarkably good effect in removing intes- 
tinal congestion, and consequently in relieving hepatic engorgement. 
Those who have remarked the relief which a flow of blood from piles 
gives in cases of hepatic engorgement with dyspepsia, will recognise the 
value of depletion of this kind, and will imitate the natural mode of relief, 
by art. Hence the use of leeches applied to the anus in cases of intesti- 
nal congestion and hepatic or splenic engorgement. There is no neces- 
sity here for applying a great number of leeches — three or four every 
second day will be quite sufficient, and we have found this number answer 
every necessary purpose. In addition to local bleeding and attention to 
diet, I ordered this lad to take a few grains of blue pill once a-day, not 
with the intention of affecting his system, but merely with the view of 



602 CLINICAL MEDICINE. 

keeping up the free action of the bowels. I continued the mercury only 
as long as the tenderness of the liver remained ; for experience has shown, 
that in those cases of ague cake where there is merely enlargement of the 
liver without tenderness, mercury is a bad remedy. 

In cases of this kind, where the stage of active congestion is past — 
where there is no fever — where the tenderness is removed, and nothing 
but the increased size of the liver remains — how are you to accomplish a 
cure ? First, by inserting one or two setons over the liver ; and secondly, 
by the use of iodine and tonics. The use of setons in cases of this de- 
scription is well known, and needs no comment. I recollect the case of 
a lady, who, after several attacks of jaundice, got chronic enlargement of 
the liver. The right lobe of the liver, which was the portion chiefly 
affected, extended down towards the crest of the ilium, and was exces- 
sively indurated. This state had occurred after the patient had used 
mercury and had been copiously salivated. Two setons were inserted 
over the region of the liver, and these produced rapid diminution of the 
enlargement, and a perfect cure. 

With respect to tonics, I may observe, that they prove extremely useful 
in chronic enlargements of the liver and spleen. We are in the habit of 
using, in this hospital, a combination somewhat similar to, the celebrated 
Bengal spleen powder ; it consists of vegetable and mineral tonics, com- 
bined with a vegetable purgative — as, for instance, aloes — and we have 
seen the best results from its use. With respect to iodine, it is a valuable 
adjuvant in such cases, particularly where the system has been much de- 
ranged, and where mercury would be likely to run down the patient. 
Here iodine gives vigour to the constitution, and tends in a very remark- 
able manner to promote the absorption of the morbid products, on which 
the enlargement chiefly depends. 

Let me now refer you briefly to the case of Catherine M'Donnel. This 
girl is labouring under an attack of chorea of considerable standing, and 
is at present about fourteen years of age. I mention this because it is not 
improbable that the appearance of the catamenia, which frequently come 
on about this period, may have some influence on the future progress of 
her complaint. She states that her disease commenced about seven years 
ago, and that ever since she has been subject to its attacks at various 
times. Her health is somewhat impaired, but not, however, to such a 
degree as to prevent her from following her usual avocations. Her pre- 
sent attack commenced about three weeks ago. 

It is unnecessary for me to enter into any description of the convulsive 
motions of the limbs, and other symptoms which characterize chorea ; 
neither is it my intention to enter into the general history of the disease : 
you will find an admirable account of its symptoms, pathology, and treat- 
ment, in Copland's Dictionary. I shall merely remark, with reference to 
this case, that there is no headache, and an accurate examination has 
failed in detecting any symptoms of determination to the head. Neither 
have we derangement of muscular motion during sleep ; the girl's sleep 
is tranquil and regular. There is no evidence of gastric derangement 
present. She relishes her food, and, what is rather singular, her appetite 
is better during the attacks than during the intervals. Her tongue is clean 
and moist, but her bowels are inclined to constipation. It is of import- 
ance to bear in mind here, that her symptoms do not appear to have any 
connection with cerebral or gastric derangement. She has no headache, 



CHOREA. 603 

flushing of the face, noise in the ears, or throbbing of the temporal arte- 
ries, and there is nothing but constipation to show that the digestive 
organs are out of order. I dwell on these two circumstances particularly, 
because some persons have attributed chorea to cerebral irritation, and 
others to indigestion and gastric derangement exclusively. I am quite 
ready to grant that it may be produced occasionally by either of these 
two causes, and that the presence of either will tend to aggravate it, but 
am inclined to look on chorea as chiefly a nervous disease, and to be 
cured chiefly by nervous medicines. Dr. Copland's remarks upon this 
question are excellent, and deserve to be attentively studied. For my 
own part, I think that in this, as in many chronic diseases where indi- 
gestion exists, it is often a consequence, not a cause, and is produced by 
debility of the vital powers of the stomach and intestines, organs which 
are affected by causes acting on the whole organization. Thus a too 
rapid growth, premature or unnatural sexual indulgence, confinement, 
want of exercise, of rest, care and anxiety, &c. &c, may each occasion 
a weak state of every organ of the body, including debility of the sto- 
mach. In a girl of this age, who labours under constipation, it is always 
proper to commence with the use of purgatives, and I have accordingly 
ordered her some pills, composed of aloes and capsicum ; but I would 
not persevere in the purgative plan any longer than was necessary for 
removing constipation. What I mainly depend on for removing the dis- 
ease is tonics, one of the best of which is carbonate of iron, in doses of 
half a drachm four times a-day. There was a controversy between Dr. 
Billing and Dr. Johnson, with respect to the doses of carbonate of iron to 
be employed in this disease ; and it is asserted, that in cases where doses 
of half a drachm, three or four times a-day, will not succeed, a cure may 
be effected by giving three, four, or even five drachms, frequently in the 
day. With regard to this subject, I must confess that I am for moderate 
doses ; and I think, in general, as much good may be accomplished by 
half a drachm or a drachm, three or four times a-day, as by much larger 
doses. I have accordingly ordered this girl to take half a drachm four 
times a-day, and will persevere in the use of the remedy until we have 
given it a fair trial. The carbonate of iron tends, in general, rather to 
produce a relaxed than a constipated state of the bowels, and consequently 
is peculiarly well adapted to chronic cases of debility. The mistura ferri 
aromatica, in moderate doses, is another excellent formula. When we 
have to deal with constitutional weakness, which has arisen gradually, 
and continued long, we must trust more to the operation of general physi- 
cal influences than to medicine ; and in graduating the doses of tonics, 
we must remember that it is impossible in such cases suddenly to 
strengthen ; we must therefore rely upon the gradual operation of tonics, 
given tor a long continuance, and in moderate doses. This rule should 
never be lost sight of in the treatment of chronic diseases ; important as 
it is, most practitioners seem little influenced by it, or perhaps they are 
altogether ignorant of it, otherwise we should not see them using concen- 
trated and powerful tonics in such large and repeated doses in chorea. 
Another general rule as to the use of tonics in chronic diseases — usually 
you will be more successful with mild and diluted than with powerful 
and concentrated medicines. Thus, for example, cinchona in powder is 
often preferable to sulphate of quinine in chronic diseases. 

There is a very curious case of paralysis agitans at present in the female 



604 CLINICAL MEDICINE. 

chronic ward, which claims a few remarks. You must have all remarked 
the patient, Ellen Davis — a young woman about twenty-five years of age. 
She has a most peculiar expression of countenance, and, as her disease is 
rather a rare one, I beg that any gentleman who has not seen it, will take 
the opportunity of paying her a visit. According to the account which 
she gives of herself, the disease appears to have originated in a sudden 
and violent mental emotion. The poor girl, like most of the lower class of 
country people, happened to be a firm believer in the existence of ghosts 
and such like nonentities, and this superstition has formed the source or 
exciting cause of the disease in question. She was, unfortunately for her- 
self, located in a very uncomfortable situation, her house being close to a 
road between two churchyards, a complete thoroughfare for ghosts, and 
where figures of a very questionable description had been frequently seen 
by many of her neighbours. Some of her acquaintances, who were aware 
of the frightful notions she entertained about personages of this kind, 
resolved to amuse themselves at her expense, and played oflf a practical 
joke of a very cruel nature. A churn-dash was procured, to which a sheet 
was appended, so as to form no unapt representation of a sheeted head- 
less corpse, and this was dandled between two trees by means of a rope. 
The poor girl, who happened to be going to bed at the time, was utterly 
appalled by the sight of what she conceived to be one of these ghosts 
sweeping through the air, and immediately dropped down in a state of 
total insensibility. The fright deranged her nervous functions in an extra- 
ordinary degree, she became vertiginous, lost the use of her limbs on one 
side, and took to bed, from which she states she did not get up for three 
months. 

The history of this case is of course extremely uncertain. In chronic 
cases, and among patients in her class of life, you can seldom expect to 
get an accurate or satisfactory account. It is quite clear that she had he- 
miplegia, but whether it arose from the fright or not we cannot exactly 
say. The symptoms of hemiplegia after some time began to decline, and 
she gradually regained the power of walking. This, however, is but 
feeble, and though it is now seven years since the occurrence of the attack, 
the muscular power of the limbs is very slight. She had also during the 
progress of her complaint an attack of amaurosis, which she says deprived 
her entirely of sight for nearly a year, and that after this period she re- 
covered the use of one eye completely, but the other still remains amau- 
rotic, and she can distinguish objects with it very imperfectly. At present 
she affords a very remarkable specimen of paralysis agitans. She cannot 
walk slowly, and when she has commenced walking she cannot stop with- 
out considerable difficulty. The muscles of the extremities, face, and 
tongue are very little under her control, and are in a state of almost per- 
petual motion. The muscles of the eyelids and eyeballs are also similarly 
affected, and this gives to her countenance a strange and peculiar expres- 
sion. You will find an excellent description of this disease in Dr. Elliot- 
son's lectures ; a very interesting case is also detailed in Dr. William 
Stokes's lectures, published in Renshaw's London Medical and Surgical 
Journal. 

It would appear that in this disease the muscles are not by any means 
beyond the control of the will, but they are so influenced by the operation 
of some other unknown cause, that their motions are more or less impefect 
and inadequate. She can walk quickly with tolerable ease, for in walk- 



PARALYSIS AGITANS. 605 

ing quickly the muscles are contracted more rapidly, and the will more 
strongly exercised, so that the obstacles to regular motion are in a great 
measure overcome, but when she walks slowly, time is given for the cause 
which produces the anomalous motions to come into play, a spasmodic 
state is established, and the muscles cease to obey the will so implicitly. 
I knew a gentleman who had a very curious form of this paralysis agitans. 
When about to walk, he was obliged to have himself balanced, and set 
off by some other person, just like a piece of machinery. When once set 
a-going, and on a smooth road, he went on very well for a considerable 
time, but if interrupted by a hill, or by the unevenness of the ground, he 
was compelled to run backwards in a right line until stopped by some one, 
and so little control of his motions had he at this time, that if a pond or 
precipice lay behind him, he could not prevent himself from tumbling over 
it. I have occasionally seen him under such circumstances, and the ap- 
pearance he makes is singular and ludicrous. He goes backwards until 
he meets with a wall or some other object which resists his further pro- 
gress. This is a very curious circumstance as connected with the nature 
of the disease. 

I do not intend at present to enter into any inquiry respecting the nature 
and treatment of paralysis agitans. The prognosis of the disease appears 
to be, a priori, unfavourable, from the total want of any exciting cause 
which might be discovered and removed. If the disease consisted in con- 
gestion of the head or spine, or if there was any apparent lesion by the 
removal of which we could hope to effect some good, w T e might entertain 
a more favourable opinion with respect to its termination, but it unfortu- 
nately happens that in too many cases we can do nothing more than ob- 
serve the curious phenomena which it presents. 

Let me now direct your attention to the case of a man named Murphy 
in the chronic ward, who came in with bronchitis accompanied by ana- 
sarca. He had old bronchitic cough, copious expectoration, and ortho- 
pnea; but he had no symptom of disease of the heart; his pulse was regu- 
lar and rather slow, he had also albuminous and scanty urine, but without 
any fever, thirst, or nausea. The recent origin and sudden appearance 
of the disease induced me to look upon it as a case of acute dropsy, and 
I commenced the treatment by antiphlogistic measures, which, as you may 
have perceived, have been followed by remarkable benefit. What I wish 
to call your attention to particularly in this case, is the state of the patient's 
urine. On his admission, we found that his urine was highly albumi- 
nous; wmen submitted to the action of heat at the temperature of 170° it 
coagulated rapidly, and showed distinct traces of the presence of a large 
quantity of albumen. Yet under the use of opium in moderate doses this 
man's urine became in two or three days perfectly free from every trace 
of albumen, and has continued so ever since. 

Now this case alone would be a sufficient refutation of the opinions of 
those who look upon albuminous urine as a pathognomonic sign of disease 
of the kidneys, as described by Dr. Bright, and who are in the habit of 
marking such cases in the hospital as cases of "Bright's Kidney." It ap- 
pears rather strange, as in our case, that a man should have " Bright's 
Kidney" to-day, and not have it the next day. We have had a great 
many instances of this kind, and in various cases which came under treat- 
ment in this hospital, I have shown that this state of the urine may depend 
on mere functional disease of the kidney. Indeed, nothing is more com- 



606 CLINICAL MEDICINE. 

mon than to meet albuminous urine in the dropsy which succeeds scarla- 
tina, and yet most of the patients perfectly recover. I had lately an op- 
portunity of examining the kidneys of a boy named William Young, who 
was admitted into Sir Patrick Dun's Hospital on the sixth day from the 
commencement of anasarca after scarlatina. This boy's urine had a spe- 
cific gravity as high as 1027, and contained an enormous proportion of 
albumen. He died suddenly of convulsions the fourth day after his ad- 
mission. His kidneys were in every respect healthy. 

One word with respect to the diuretic remedies, which in this case I 
have employed with remarkable success. Having removed, the acute 
symptoms by antiphlogistic treatment, I prescribed the following decoc- 
tion : — 

R. Decocti hordei, lb. j. 

Sacchari albi, ^j. 

JNitratis potassse, ^ij. 

Acidi nitrici diluti, 5J. 

Spiritus aetheris nitrosi, ^j. 
Two tablespoonfuls to be taken every second hour. 

This is an excellent mixture, and well suited to the stage intermediate 
between the acute and chronic form of dropsy, where you wish to excite 
the action of the kidneys, and are afraid of stimulating the system gene- 
rally. It has acted very favourably in the case before us, having increased 
the urinary discharge very considerably without producing any constitu- 
tional excitement. 



LECTURE XLVI. 

Glanders and button-farcy in the human subject — Particulars of a case of glanders, with the 
post-mortem appearances — Remarks on the variety of skin diseases produced by the intro- 
duction of an animal poison into the system — Uase of button-farcy — Analogous appearances, 
where, as in typhus, an animal poison is sometimes generated in the body — Furuncular 
inflammation, or carbuncle, generated by animal poison ; also tubercles — Sometimes a pre- 
ternatural whiteness precedes the purple hue of mortification — Remarks on phlegmasia 
dolens — Phlegmasia dolens of the eye. 

In pursuance of my intention, as announced in a former lecture, I shall 
proceed to-day to the consideration of two affections resulting from ani- 
mal poison, one of which has been but recently introduced to the notice 
of the medical profession ; of the other, I am not aware that there are any 
published cases in existence. I allude here to glanders and button-farcy 
in the human subject. 

The profession is chiefly indebted to the researches of Dr. Elliotson for 
the first accurate account of glanders in the human subject — a disease 
which has now excited a very large share of attention here and on the 
continent. Many other observations, published since Dr. Elliotson un- 
dertook the illustration of this disease, have established the fact, that the 
morbid matter secreted by horses labouring under glanders may commu- 
nicate the infection to the human subject, and thus give rise to a loath- 
some, painful, and generally fatal disease. From the notices which I 
have been able to collect, it appears that glanders in man is of very fre- 
quent occurrence in Ireland — so frequent, indeed, that I think the legis- 



GLANDERS. 607 

lature is called on to imitate the wise example of the Prussian govern- 
ment in placing glandered horses under the surveillance of the police. 

Like many other animal poisons, that of glanders does not seem capable 
of affecting every individual indiscriminately: indeed the average sus- 
ceptibility must be small, for grooms and veterinary surgeons take few or 
no precautions in examining the diseased animals ; and yet the propor- 
tion infected, compared with the number exposed, is by no means consi- 
derable. That such persons exhibit great carelessness in examining glan- 
dered horses appears from the directions given in books on farriery, " that 
the finger should be introduced into the nostrils for the purpose of ascer- 
taining whether certain spots suspected to be ulcers are so or not." Now, 
when the viscid gluey nature of the discharge from the nostril is taken 
into account, we cannot but conclude that this operation of introducing 
the finger into such a mass of vitiated and poisonous secretion would more 
frequently prove the means of infection, were the human constitution very 
susceptible of the poison — for we are to recollect that the fingers of such 
persons are seldom free from scratches and abrasions. 

I shall now read the following case of glanders in the human subject. 
It is one of extreme interest, and has been most faithfully and graphically 
detailed. It occurred in the Richmond Hospital, and has been commu- 
nicated to me by Dr. M'Donnel, one of the surgeons of that institution. 
You will find in it many points of resemblance to a series of cases trans- 
lated from a German journal, and published in the Medico- Chirurgical 
Review : — 

" Patrick Wallace, a healthy muscular man, aged twenty, was admit- 
ted into the Richmond Surgical Hospital on the 6th of October, 1836. 
It is stated that he had been in care of a glandered horse — driving, clean- 
ing, &c. — and that he had been in the habit of drinking out of the vessel 
from which the horse drank. It appeared, also, that he had had an abra- 
sion on one of his ears. On admission, he had much the appearance of 
a person labouring under cynanche tonsillaris: he could only open his 
mouth to the extent of half an inch ; this was the only uneasiness com- 
plained of. The left tonsil was very much enlarged, red, hard, and pro- 
jecting towards the middle line ; no fluctuation could be felt ; there was 
a general fulness about the angle of the jaw, extending upwards nearly as 
far as the zygoma. The submaxillary gland on the same side was also 
enlarged and indurated. These symptoms had been ushered in by fever- 
ishness, a few days previous to admission. He was ordered to have eight 
leeches to the throat, to be followed by a poultice, and a bolus composed 
of calomel and jalap. 

" Next day the external swelling was found to be increased ; greater 
difficulty of opening the mouth ; the tonsil still hard and swollen. Twelve 
leeches were applied to the fauces, and the patient took the tartar-emetic 
mixture of the hospital, with sulphate of magnesia. 

" On the 15th of October, the disease is reported to be on the increase. 
Tonsil still hard, but no fluctuation ; left side of the face greatly swollen ; 
eye of the same side nearly closed, from tumefaction of the lids ; general 
inflammatory appearance over the cheeks, and great hardness of the tis- 
sues about the angle of the jaw of the same side, extending towards the 
chin ; several circumscribed spots of redness, varying in extent from the 
size of a sixpence to that of a halfpenny, with irregular margins, scat- 
tered over different parts of the body ; two pustules observable on the 
left leg. 



608 CLINICAL MEDICINE. 



u 



16th. — A vesicle containing a yellowish serum observable on the left 
tonsil ; the same inability of opening the mouth continues ; increase of 
swelling over the left side of the face ; a small abscess has formed on the 
posterior part of the left fore-arm ; some delirium during the night ; three 
evacuations from the bowels. The tonsil to be brushed over with a solu- 
tion of nitrate of silver ; a blister to the fauces ; the tartar-emetic mixture 
to be continued. 

" 17th. — Some sleep during the night, interrupted by delirium of a low 
muttering character. Patient appears willing to answer questions, but 
cannot, from obstruction in the mouth. This, however, lasts but for a 
moment, and he then lapses into a state of incoherency. Mouth open to 
the extent of half an inch ; left eye closed ; considerable swelling of the 
left side of the face, which is indurated, hot, tense, and shining ; all the 
glands on both sides of the jaw, but particularly on the left, are swollen 
and hard ; same state of tonsil ; nares dilated ; breathing stertorous, 
somewhat hurried, about 28 in the minute, and interrupted by frequent 
sighs. Pulse very small, rapid, intermitted, and cannot be counted ; skin 
hot, tongue furred, teeth covered with sordes. He complains of great 
thirst, but says he feels no pain ; it is evident, however, that he feels 
great uneasiness in the joints and limbs when moved. There is, how- 
ever, no swelling or redness of the joints ; there is no discharge from the 
nostrils, nor is there any perceptible ulceration of the mucous membrane 
of the nose. No apparent affection of the absorbent glands in any other 
part of the body. 

" During this period, vesicles and pustules of various sizes, and at va- 
rious stages of growth, had made their appearance on different parts of 
the body, particularly on the back. They varied in size from the head 
cf a pin to the section of an almond. In the first stage they resembled 
very minute vesicles, scarcely surrounded by any inflammatory border, 
and containing a limpid serum. In the second stage, the serum was re- 
placed by pus ; there was a considerable blush of redness around each 
pustule, which at this period became greatly increased in size. When 
one of the vesicles was punctured, the serum appeared to come from a 
single cavity under the cuticle : this operation did not produce any subsi- 
dence of the tumour, a considerable hardness still remaining in the cutis 
or beneath it, with a cavity in the centre in which the serum was con- 
tained. A number of achores existed in various parts, congregated to- 
gether, and not much larger than the head of a pin. These clusters were 
surrounded by white raised margins, having much the appearance of 
wheals, and about a line and a half or two lines in breadth ; between 
these margins and the achores there existed a line of redness. The whole 
taken together are rather of an oval shape. There also existed numerous 
inflammatory spots on the right shoulder, left arm, and other parts of the 
body. These were of a dark brown, approaching to a livid colour ; when 
pressure is made on them the colour disappears, but returns immediately 
when it is removed. On running the finger over them, a small hard 
tumour was felt in the centre ; the margins of these spots were irregular. 

u On the 17th, the character of the disease became more plainly devel- 
oped : at three o'clock, p.m., pus in considerable quantity was observed 
to issue from both nostrils. The patient was ordered to take the solution 
of chloride of soda internally, in drachm doses, three times a-day ; and 
also a mixture composed of carbonate of ammonia, liquor aetheris oleosus, 



GLANDERS. 609 

and camphor-mixture. At five o'clock, p.m., he was found half out of 
bed, his head resting on the pillow ; still able to express his wants; pulse 
not to be counted ; legs and feet cold ; breathing stertorous ; numerous 
stigmata scattered over the surface of the body. The purulent discharge 
from the nostrils has ceased, but there is a discharge of mucus from the 
mouth, with considerable fetor of breath. 

" Eight o'clock, p.m. — A copious perspiration has broken out over the 
body ; face red, tense, shining, and very much swelled ; swelling has 
now extended to the right side of the face ; right eye nearly closed ; can 
open the left better; a few pustules have made their appearance at the 
inner canthus of the eye. Pulse, tongue, and skin, as in last report ; 
delirium and muttering continue. 

" Died at 4 o'clock, a.m., October 18th. 

" On examining the body ten hours after death the redness was found 
to have disappeared from the face ; the glands about the left angle of the 
lower jaw as before mentioned : they were found matted to the surround- 
ing parts* The cellular tissue covering the submaxillary and parotid 
glands was infiltrated with serum, and indurated ; numerous depositions 
of pus were found in the tissue of the sub-maxillary and parotid glands. 
The brain was firm, but its ventricles contained a considerable quantity 
of fluid; the arachnoid membrane was opaque in many places ; several 
patches of vascularity were observed on the pia mater. The lungs pre- 
sented a congested appearance ; numerous pustules were scattered over 
their surface — some separate, yellow in the centre, and surrounded by an 
ecchymosed border ; others existing in clusters. They resembled, in 
every respect, those found on the* surface of the body. The lining mem- 
brane of the larynx was very much inflamed, especially about its upper 
part and about the epiglottis. The inflamed parts in this situation were 
of a livid hue. There was some appearance of vesicles in the trachea, 
but this could not be satisfactorily ascertained. The bronchial tubes were 
filled with mucus; the stomach contained a quantity of yellowish green 
mucus — its lining membrane presented an ecchymosed and inflamed appear- 
ance. The liver was somewhat enlarged, and adhered by its inferior 
margin to a few folds of intestine. The periosteum did not exhibit any 
appreciable deviation from the normal state." 

One of the chief things to be noticed in the foregoing case is the variety 
of inflammatory affections observed in the skin, as the result of the intro- 
duction of an animal poison into the system. There was, in the first place, 
the general diffused redness of the face, then superficial inflammatory 
spots on the shoulders and arms, resembling erythema nodosum ; in the 
next place, scattered pustules of various sizes, commencing in the form of 
a vesicle, which afterwards became a pustule surrounded by an inflam- 
matory zone ; and lastly, achores congregated together and surrounded 
by an elevated white margin, within which there existed an inflammatory 
ring of a red colour. Another point worthy of notice is the state of the 
lungs and bronchial mucous membrane. The lining membrane of the 
larynx, particularly in the vicinity of the epiglottis, was inflamed and of 
a livid colour, and there was an indistinct appearance of vesicles in the 
trachea. But what was particularly deserving of note in the lungs, was 
the existence of pustules on their surface, bearing the closest resemblance 
to those found on the surface of the body. It is not stated whether there 
was any appearance of vesicles or pustules in the nose, pharynx, or 
40 



610 CLINICAL MEDICINE. 

oesophagus ; but we are told that the stomach was ecchymosed and 
inflamed. 

The following case was witnessed by myself and Dr. Halahan, and 
seems more nearly allied to the variety of glanders termed button-farcy. 
I regret that want of time has prevented me from arranging its details in 
a form more worthy of your attention ; and were not the disease one of 
comparatively rare occurrence, I should not have ventured to lay the case 
before you in its present imperfect state. 

The subject of this case was a gentleman residing in Rathmines, an 
extensive proprietor of horses, and who, having originally graduated as a 
surgeon, exhibited much skill in the veterinary art. About the time of 
his illness he had some horses in his establishment labouring under glanders 
and button-farcy, to which he paid particular attention. After having la- 
boured for some days under considerable lassitude and derangement of the 
stomach and bowels, he was attacked on the 8th of July with rigors, fol- 
lowed by great thirst, excessive heat of skin, and pains in his limbs. 
The moment he felt himself attacked in this way, he said he was sure 
that he had got some dangerous infection from the horses, and would 
never recover. He took some blue pill and colocynth, which produced 
a few dark and very fetid evacuations. On the 9th, hi3 pulse was 94, 
his urine very high-coloured, his thirst and feverish symptoms rather 
increased, and he suffered greatly from constant nausea and vomiting. 
A tumour now began to appear about three inches above the inner ankle 
of the right foot. He applied a poultice over it, but was obliged to 
remove it in a short time, in consequence of the pain occasioned by its 
weight. The tumour was about the size of half a walnut, of a dull red 
colour, tense, shining, and exquisitely painful. Its external aspect was 
peculiar, and might be compared to something intermediate between 
boil and a spot of erythema nodosum. On the 10th, another tumour of 
the same character appeared near the outer ankle of the same leg ; and 
in this way the disease went on, tumour after tumour appearing on dif- 
ferent parts of the body, with an increase of the feverish symptoms, until 
the 20th of July, when he was first seen by Dr. Halahan. At this time 
several tumours had appeared on different parts of his body ; there was 
one of an extremely painful character on his head, and he complained of 
great tenderness and pain along the right clavicle. His thirst was still 
urgent, his restlessness excessive, the slightest motion gave him exquisite 
pain, and sleep had completely abandoned him. He had endeavoured 
to regulate his bowels by purgative medicines, and had applied leeches to 
the tumours and to the clavicle at various times, but without any decided 
benefit. There were eight or nine tumours on different parts of the body, 
of the character before mentioned, without any tendency to suppuration, 
and so exquisitely painful that he could only bear a single sheet over him. 
The inflammation about the clavicle, which was of a diffuse character, 
had extended up the neck and over the right shoulder ; there was not 
much swelling, except about the clavicle ; the colour of the affected parts 
was a peculiar dusky red. Immediately over the clavicle two vesicles 
were observable, filled with a transparent fluid. Three dozen of leeches 
were ordered to be applied over the clavicle and shoulder, and the patient 
was directed to use chicken-broth, beef-tea, and other light nutritious 
articles. 

On the 21st, all symptoms are stated to be on the increase. His fever, 



BUTTON-FARCY. 611 

thirst, and sleeplessness, are undiminished ; his tongue furred and dry ; 
his teeth covered with sordes ; his pulse small, weak, and rapid ; his 
nausea and vomiting not so troublesome. He had received no benefit 
from the application of the leeches ; the swelling and stiffness of his 
neck was increased, and he had now some difficulty of swallowing. The 
erysipelatous surface of the neck, clavicle, and shoulder, were lightly 
brushed over with lunar caustic, which gave the patient an agreeable 
sensation, and from which he stated that he derived much relief. This 
was repeated the next day at his own request, and with equal benefit ; 
the difficulty of deglutition diminished, and for two days he went on 
pretty well. On the 25th, there was an evident increase of fever : the 
tumours over the body and limbs were increasing in size and number ; 
and his anxiety, restlessness, and sufferings unabated. He had taken 
alterative doses of calomel and James's powder, and his bowels had been 
regulated by mild aperients and enemata. I saw him for the first time on 
the 28th. His pulse was then 98, small and easily compressed ; his thirst 
excessive ; his restlessness and agony such as would strongly excite the 
pity of persons most conversant with scenes of human suffering. He had 
several tumours over different parts of his body, all exquisitely painful, 
and in their aspect something between boil and erythema nodosum. 
Some of them were hard to the touch ; others, which appeared more 
advanced, were softer and had a boggy feel. There was, however, no 
appearance of any thing like suppuration. He was ordered sulphate of 
quinine, chicken-broth, ale, and other light nourishment, and an opiate at 
night. On the 31st, a tumour appeared on the right side of his forehead, 
larger and more painful than any of the rest. Another of a similar 
character showed itself on the right clavicle, which had been previously 
affected. Shortly after their appearance, vesicles were observable on 
their surfaces, such as generally precede mortification in cases of anthrax 
and malignant carbuncle. Next day he was evidently worse ; his pulse 
was 108 ; his fever, pain, and restlessness, unabated ; and a miliary 
eruption began to make its appearance over his chest and abdomen. The 
vesicles now began to increase on the surface of the tumour ; his fever and 
restlessness were aggravated ; and his mind, which had been hitherto 
collected, began to wander. His restlessness was so excessive, that he 
could not remain for a moment in the same position ; and being a person 
of much mechanical ingenuity he had a set of pulleys constructed and fas- 
tened to his bedstead, so that he could move himself in various directions. 
His medicines and diet, with the addition of claret, and opiates at night, 
were continued as before. 

On the 6th of August he was still worse ; the tumour on the head con- 
tinued to enlarge, and decided sloughing had taken place. The tumour 
on the clavicle presented the same aggravation in appearance and cha- 
racter, and a fresh tumour had appeared on the back of his head. A pus- 
tular eruption now began to make its appearance over his body, chiefly 
over the abdomen and limbs ; his symptoms became aggravated in every 
respect; the delirium and watchfulness increased; and he died on the 
10th of August, about thirty-three days from the commencement of the 
disease. He attributed his illness to attending horses, four of which had 
died of button-farcy ; and what is also curious, his nephew, who had also 
been engaged about the diseased animals, had fever of a typhoid charac- 
ter, with maculse of a larger sort than usual, but ultimately recovered. 



612 CLINICAL MEDICINE. 

The symptoms of glanders in the human subject have been so fully de- 
tailed by Dr. Elliotson, Dr. Hutton,* and others, that it only remains for 
me to make a few observations connected with this subject. In the first 
place, it may be observed that most diseases produced by the deleterious 
effect of animal poisons on the economy, show a tendency to cause not 
only fever, often of a malignant character, but also various forms of ex- 
ternal disease, chiefly limited to the superficial glands, subcutaneous cell- 
ular tissue, and skin. In urticaria, small-pox, and measles, the external 
disease is chiefly limited to the skin ; in scarlatina, we have often swell- 
ing of the parotid gland, with infiltration of the adjacent cellular tissue in 
addition to the cutaneous eruption ; in syphilis, and cases of dissecting 
wounds, we have disease of the skin frequently combined with an affec- 
tion of the superficial lymphatic glands. The same observation applies 
to typhus, many cases of which are characterized by an eruption of spots 
over different parts of the body, or by the occurrence of what are termed 
petechias. On these matters I need not enlarge, as you are all acquainted 
with them ; but that vesicles and pustules very similar to those observed 
in dissecting wounds, and other diseases produced by the direct intro- 
duction of animal poison into the system, may arise from the action of 
morbid changes spontaneously occurring in the body, is afact which ad- 
mits of being proved, and opens to us a new and interesting field of in- 
quiry. Thus, in cases of typhus, where the effect of a pressure or some 
other accident has occasioned bed-sores of a bad character, and even 
where there are no bed-sores present, I have on several occasions seen 
low secondary fever produced, and have observed vesicles or pustules 
appear on the skin, similar to those described by Mr. Colles as accom- 
panying the fever of dissecting wounds. An example of this occurred 
some time ago at this hospital, and you have recently witnessed another 
in the case of a young man recovering from typhus. It might be argued 
that the secondary fever and eruption in such cases arise from the ab- 
sorption of morbid matter into the system, and I am willing to admit that 
there is some colour of argument for this statement, where the patient 
labours under bed-sores of a bad and gangrenous character ; but that this 
explanation is not the true one appears from the case of the young man 
to which I have alluded. He had no bed-sores to account for the secon- 
dary fever and eruption ; and we can only explain the circumstance by 
supposing that it is the result of a poison generated in the system during 
the course of fever. This is particularly deserving of notice, as I am not 
aware that any author on typhus has noticed this symptom, or pointed out 
the circumstances under which it occurs. f The same phenomenon is oc- 

* See Reports of the Dublin Pathological Society. 

■f While these pages were passing through the press, I have been informed by my friend 
Surgeon MacDonneli., Clinical Clerk to Dr. Stokes and me, at the Meath Hospital, of a case 
at this moment under the care of my talented colleague ; and as it strongly corroborates the 
views above mentioned, I shall take the liberty of introducing it here ; — 

A man, aged 40, was admitted into the Meath Hospital, Oct. 29, 1842, labouring under 
typhus fever, with delirium tremens and pneumonia of the right lung. He slowly but gradu- 
ally recovered till the 10th of November, when two of the characteristic vesicles of Colles were 
observed on the palmar aspect of the right thumb. It was remarked by my colleague to the 
pupils, that these pustules indicated an extremely bad state of the constitution, and that they 
were, in all probability, but the precursors of more serious symptoms. From this period till 
the 17th, his pulse remained quick (140), weak, and faltering; the pneumonia remained sta- 
tionary ; and in addition, he was attacked with pleuritis of the lower and front part of the right 
side and pericarditis. These latter complications yielded quickly to treatment, but the pneu- 



MORBID POISONS GENERATED IN THE SYSTEM. 613 

^asionally observed, where, in consequence of external injury, diffuse cell- 
llar inflammation has taken place. Thus, several years ago, a woman 
was admitted into the Meath Hospital, who had diffuse cellular inflamma- 
ion in consequence of receiving a kick on the chest. After a few days, 
Dolles's pustules appeared on different parts of the body, and she died 
with symptoms of croup. On dissection, the croupy symptoms were found 
o depend on an eruption of vesicles filled with opaque serum, over the 
ining membrane of the larynx and trachea. Something analogous to this 
was observed in the case of Wallace ; and the coincidence is further 
strengthened by the frequent occurrence of disease of the lining membrane 
f the larynx and trachea in many other febrile affections, accompanied 
)y cutaneous eruption — as small-pox, measles, syphilis, and scarlatina. 

Another point which is deserving attention with reference to the pheno- 
nena of external disease, in cases where animal poisons have been gene- 
ated in the system or arisen from infection, is the occurrence of tumours 
n different parts of the body, partaking of the characters of furuncular in- 
lammation or carbuncle, and running through a somewhat similar course. 
These tumours formed a very prominent feature in the case of Wallace; 
and, in the gentleman who laboured under button-farcy, they constituted 
one of the most important symptoms of the disease. We also observe 
something similar to this in that form of venereal which Mr. Carmichael 
terms tubercular, and which is characterized by the appearance of small, 
hard, dark red tumours, on various parts of the body, which exhibit a very 
imperfect tendency to suppuration, and frequently give rise to sores of a 
bad and unfavourable character. Another circumstance observed in Dr. 
M'Donnell's case deserves some share of attention; I allude to the white 
elevated margins, like wheals, around the redness which more immedi- 
ately encircled each cluster of,achores, and which we are to look upon as 
in a less advanced stage of its progress, being as it were, only the first 
stage of the latter. It is a curious fact, that on many occasions a pre- 
ternatural degree of whiteness precedes the redness and congestive pur- 
ple hue which ushers in mortification. This is generally known in 
the case of the nose when frost-bitten, and which always appears preter- 
naturally white in the commencement. Something analogous to this was 
observed in some cases of bad typhus treated here in 1826 and 1827. 
The nose sometimes assumed a peculiar white colour, and not unfrequently 
exhibited a tendency to mortification. When first seen it had a preterna- 
tural whiteness, and looked very like a nose made of white wax; in the 
course of a few hours it changed to a purplish red, and exhibited symp- 
toms of approaching gangrene. Again, in urticaria, we often see some 
portions of the inflamed skin assume a white colour, and the same occur- 

monia continued in the same state as before On the 19th, the report states, that he slept 
very little, was kept awake by pain extending down the inside of left leg, and had frequent 
short rigors. On examining the limb, it was found to present the usual appearance of phleg- 
masia tlolens ; it was white, its symmetry perfect, but by measurement in different situations, 
was found to be three inches thicker than the opposite one. There was very little effusion 
into the knee-joint; the power of motion was almost lost, and he complained of excessive pain 
in the groin and along the course of the saphena vein, greatly increased by pressure ; the 
pustules had burst and formed scabs, which, when they dropped off, left the skin underneath 
whole and healthy. As the man is still in hospital, I am unable to give the termination of the 
case, but which, as far as it goes, is, I think, strongly confirmative of my views. It is worthy 
of note, that in this case the poison, whatever it was, that gave rise to the pustules and subse- 
quently to the phlegmasia dolens, was generated in the system itself during the course of a 
typhus fever; here there was no bed-sore, wound, or other local affection, which could be 
supposed capable of originating the poison. 



614 CLINICAL MEDICINE. 

rence may be noticed likewise in the wheals caused by nettles or the stings 
of bees. In general, we connect the idea of integumental inflammation 
with the appearance of redness; and this phenomenon is explained on the 
hypothesis that a preternatural quantity of blood is circulating in the in- 
flamed parts. How, then, are we to account for the facts I have men- 
tioned ? To what cause are we to attribute the co-existence of increased 
vascularity, and a remarkable whiteness or pallor of the parts? — a state 
displayed in a very remarkable manner in phlegmasia dolens. I think the 
explanation is not very difficult when we recollect that the capillary ves- 
sels of the white tissues of the body contain no red blood in their healthy 
state. It is easy to conceive that in certain stages of inflammation the 
quantity of serous or white blood circulating in any of these tissues may 
be suddenly much increased, and that this increase may be accompanied 
by all the phenomena of inflammation except redness. In certain cases, 
as phlegmasia dolens, the colour is permanently white ; in other cases the 
white is exchanged for redness, when the inflammation has increased in 
intensity; but perhaps we should not use this expression, for the pheno- 
mena of phlegmasia dolens prove that a white inflammation may be quite 
as intense as red inflammation, — a fact which we saw exhibited in a re- 
markable manner in the case of a woman in this hospital, labouring under 
phlegmasia dolens, and in whom the disease suddenly attacked the eye, 
and destroyed it in a short space of time — disorganising it rapidly without 
the supervention of any redness during this destructive process. 

I never had any hopes of this woman's recovery, because, in addition 
to the phlegmasia dolens, she had fever and inflammation of the mucous 
membrane of the intestinal canal and lungs. She laboured under fever, 
vomiting, and irritability of the stomach ; she had a severe diarrhoea, tym- 
panitis, and a swollen state of the abdomen, with turgescence of the veins 
on its surface, so as to bear some resemblance to dropsy. She had a con- 
stant harassing bronchitic cough ; in fact, a combination of unfavourable 
symptoms, which rendered her case hopeless ; and in spite of all the usual 
remedies, stupes, leeching, blisters, &c, she grew progressively worse, 
and sank under her complicated load of disease. I shall not detain you 
by a detail of her case, and a recapitulation of the therapeutic agents 
employed in endeavouring to arrest her complaint, but shall proceed to 
make some observations with respect to the phenomena observed by Mr. 
Hudson on dissection. " On opening the thorax, there was no serum 
discovered in the pleural cavities, but there was a considerable quantity 
in the pericardium. The left pleura was adherent at all points. The 
lungs were healthy, with the exception of some edema posteriorly ; the 
bronchi contained a quantity of sanguinolent frothy fluid, but in other re- 
spects presented a natural appearance. The right side of the heart con- 
tained fibrin, the left some coagulated blood ; the valves were healthy. 
The stomach and intestines presented no sanguineous engorgement, and 
were apparently free from disease ; the liver was large and much con- 
gested ; the spleen large, soft, and almost pulpy ; the kidneys pale, with 
patches of white degeneration. The uterus exhibited nothing remarkable, 
except the loaded state of the spermatic veins, which were very large and 
tortuous ; the veins of the mesentery were also congested. The vena 
cava inferior was healthy down as far as its juncture with the renal vein, 
below which it was thickened, and filled with a fibrinous substance, vary- 
ing in its consistence, and adhering to the inner coat of the vessel. On 



PHLEGMASIA DOLENS OF THE EYE. 615 

laying bare the femoral vein, the subcutaneous cellular tissue was found 
to be infiltrated with serum, the granules of fat much firmer and more dis- 
tinct than natural, and the intervening cellular membrane thickened and 
opaque. The superficial fascia was dense, white, and of a flaky appear- 
ance, the lymphatic glands in the groin were large, full of serum, and 
closely matted together by condensed cellular tissue. It was extremely 
difficult to detach the iliac, femoral, and saphena veins, in consequence 
of their strong adhesions to their sheaths and the surrounding organised 
lymph, in which they were imbedded. These, together with the popliteal 
vein, were similar in condition to the inferior cava, except that the sub- 
stance they contained was thinner, of a brown colour, and somewhat 
purulent appearance. In the remainder of the saphena, and in the veins 
near the foot, there was a plug of coagulum, they were otherwise healthy. 
The iliac and femoral arteries contained a small quantity of blood ; the 
other arteries were empty." You perceive, gentlemen, that all these 
last-mentioned parts, so accurately detailed by Mr. Hudson, presented, 
each in succession, marks of inflammation. The subcutaneous cellular 
membrane is infiltrated, the granules of fat altered, the cells in which 
they are deposited increased in size, the superficial fascia dense, white, 
and of a flaky appearance, all indicative of the existence of inflammation. 
It is found extremely difficult to detach the femoral and saphena veins 
from their sheath, or from the firm organised lymph in which they lay. 
As the result of long-continued inflammation, a large quantity of lymph is 
poured out along the track of the vessels, and this mats them together in 
such a manner as to present considerable obstruction to their detachment. 
The veins and lymphatic glands also exhibit distinct proofs of inflamma- 
tory action. Why do I make this recapitulation ? Because I think it is 
necessary to impress upon your minds the fact that all those tissues, and 
not merely the veins or lymphatics, are engaged in phlegmasia dolens. 
Was there any part spared ? Did the cellular tissue, or the fat, or the 
external surface of the veins escape ? No — all were enveloped in the 
same inflammatory mischief.* I think you cannot have a better proof 
than this, that the phenomena of phlegmasia dolens do not depend on 
inflammation of either veins or lymphatics solely. In confirmation of this 
opinion, I may observe, that I lately saw a case, in which both saphenas 
became inflamed and obliterated, in consequence of a cutaneous eruption, 
and yet the gentleman had no accompanying phlegmasia dolens. 

Let us pass over this subject and come to the eye. W T hat is the state 
of the eye in this woman ? She awoke on the morning of the 24th of 
January with intense pain in the eyeball, and complete blindness of the 
affected eye, being unable to distinguish light from darkness. On ex- 
amination, there was immense serous chemosis discovered, so great, in 
fact, as almost to conceal the cornea, which appeared, as it were, sunk 
and buried in it. This chemosis was so exquisitely tender, that she could 
not bear the eyelids to be touched. Nevertheless, it presented a charac- 
ter totally distinct from any other species of acute chemosis we are ac- 
quainted with, its colour being almost white. The exceedingly small 
portion of cornea which was visible appeared to be opaque. 

Her symptoms continued with undiminished intensity up to the period 
of her decease. On examining the eye after death, the cornea was found 
to be perfectly transparent, and the chemosis to have nearly disappeared. 
* These views were advanced by Hull, in 1800, and subsequently advocated by Lee. 



616 CLINICAL MEDICINE. 

The iris had lost its natural grey colour, and become nearly white, and 
its surface was covered with long flakes of lymph, both anteriorly and 
posteriorly. The aqueous humour was turbid, and had portions of curdy 
lymph floating in it. The crystalline lens was opaque and of a light 
brownish tint. The vitreous humour was of a dull yellowish colour, and 
had its consistence altered, for, on opening it, the fluid which dropped 
out was thick and ropy. On this case Mr. Hamilton, who was then one 
of my clinical clerks, has made the following remarks : — u The only 
disease in which the sight is instantly destroyed is amaurosis, of which 
some instances are on record ; but it would be impossible to look on this 
as a case of amaurosis, where the eye exhibited so many simultaneous 
organic lesions. The chemosis in this case differs very much from that 
which accompanies any of the varieties of ophthalmia, or conjunctivitis ; 
in the former it was white, in all the latter it is red, of various degrees of 
intensity. There is a great difference in the manner in which sight is 
destroyed by any of the forms of ophthalmia, and that which has charac- 
terized this affection ; in the common forms we have destruction slowly 
accomplished by ulceration and sloughing of the cornea, hypopium, 
adhesions, and prolapsus of the iris, &c. Neither does it resemble rheu- 
matic or gouty inflammation of the iris ; for in these instances sight is not 
annihilated at once, and there is a degree of redness, arising from a par- 
ticular arrangement of the sclerotic vessels. The colour which the iris 
presented is also peculiar to this disease. In common iritis the colour 
never becomes so white, nor is it ever covered by the same kind of flaky 
lymph ; the lymph that is effused being a more homogeneous fluid, which 
either forms a thin layer in front of the lens, giving it a hazy appearance, 
or contracting adhesions so as to change the form of the pupil, or existing 
in the shape of globules on the surface of the iris, or gravitating towards 
the bottom to constitute hypopium. None of the writers on diseases of 
the eye whom I have consulted describe any such appearance ; nor have 
I witnessed any thing similar among the numerous cases of syphilitic and 
idiopathic iritis which are treated at this hospital. I think there can be 
little doubt of its being a disease sui generis, differing from other dis- 
eases of the eye, not only in its leading features but in all its particular 
symptoms." 

Such is the interesting detail of this remarkable case given by Mr. 
Hamilton. The woman awakes suddenly from sleep one morning during 
the progress of her complaint, feels an intense pain in the eyeball, and 
finds her sight completely gone. This is a very remarkable circumstance. 
Again, you have the cellular tissue of the conjunctiva attacked by a rapid 
inflammation of precisely the same character as that which we noticed to 
prevail so extensively in a similar tissue in the lower extremity. The prin- 
cipal part of the exhalation which results from the inflammation is deposited 
in the subconjunctival cellular membrane, forming an enormous protube- 
rance which nearly shuts out the cornea from view, exquisitely tender to 
the touch, but white and exsanguineous in its colour. I do not hesitate 
to affirm that in this new species of affection we have witnessed a case of 
phlegmasia dolens affecting the eye, perfectly identical in all its characters, 
and differing in no single material point from the inflammation which 
attacked the lower extremity. In the leg we have various tissues engaged 
in the inflammatory process, the skin, cellular tissue, adipose substance, 
fascia, arteries, veins, and lymphatics ; in the eye we have the conjunc- 



PURULENT VESICLES. 617 

tiva, iris, aqueous and vitreous humours and crystalline lens involved in 
one common mischief. Their identity is farther corroborated by the 
nature of the pain common to both, the sudden appearance of the disease, 
the exquisite tenderness of the eye, and from the fact that there is no 
other species of disease on record with which we could class this novel 
disease. It is a form of disease hitherto unknown, and I believe we may 
claim the honour of having first described it. It was not iritis, nor oph- 
thalmia, nor amaurosis. In iritis there is pain in the forehead, sight is 
not instantaneously destroyed, the conjunctiva is red and very seldom 
exhibits much turgescence ; but here, vision is annihilated as if by a flash 
of lightning ; there is a wall formed round the cornea which hides it from 
our view, but its hue is pale and bloodless. There is not a single 
feature in it by which the most anxious and critical inquirer could trace 
any resemblance between it and amaurosis, except the single and unsup- 
ported circumstance of sudden bereavement of vision. It is unnecessary 
for me to contrast it with any kind of ophthalmia, as their phenomena, 
progress, and termination, are so essentially dissimilar. All that we have 
seen of it authorizes us to conclude that we have witnessed a disease hitherto 
unknown and undescribed, phlegmasia dolens of the eye. 

Postscript. — On Purulent Vesicles. — A woman named Green was 
admitted into the Meath Hospital, with erysipelas of the head and neck, 
accompanied by high cerebral symptoms, the consequences of a contused 
wound of the scalp. On the second day of her admission, we observed 
a vesicle of a peculiar character on the right hand. It was about the 
size of a small pea, full of pus and surrounded by a base of a deep red 
hue about the size of a shilling. Between the shoulders, two more vesi- 
cles, exactly like the first, were'discovered. The erysipelas and head 
symptoms gradually disappeared under the action of mercury, and the 
vesicles burst, and left an encrustation which soon fell off, leaving a 
newly-formed and healthy cuticle underneath. 

A day or two after the appearance of the vesicles on Green, a girl who 
had been in the hospital about six weeks, labouring under general debility, 
palpitations, and excessive action of the heart, extreme irritability of the 
stomach, depending on amenorrhea of seven months' duration, presented 
on the forefinger of her left hand a well-marked vesicle, of the same size 
and character as those noticed in Green's case. Though she had a good 
number of boils in other parts, she had only the one vesicle, which also 
burst, scabbed, and the crust fell off, leaving the cuticle underneath quite 
healthy. 

In the same ward with Green was another girl named Scully, affected 
with symptoms, the consequence of suppressed catamenia, who was also 
attacked after Green with an eruption of the same kind of vesicles, on both 
hands. At first the parts became red and itchy, then small vesicles filled 
with serum appeared, which, when they had attained the size of a small 
pea, became filled with pus. Each vesicle was surrounded by a deep red 
base. Some of them were as large as those of pomphylix. One very large 
vesicle was observed to have one half distended with pus, and the other 
with serum. They were extremely itchy, and the red base was very pain- 
ful. These vesicles extended over both arms up to the elbows, continued 
longer than in the two preceding cases, and then terminated in the same 
manner. But in this instance their disappearance was immediately fol- 



618 CLINICAL MEDICINE. 

lowed by inflammation and abscesses of the left mamma, producing great 
suffering, and attended by painful periostitis of both shins. Under appro- 
priate treatment she eventually recovered. 

Two cases of dropsy, in the chronic ward, next claim our attention. 
Both have occurred in persons who have previously enjoyed tolerably 
good health, and in both the disease seemed to be unaccompanied by 
organic lesion of any important viscus. One of the patients, J. Aus- 
tin, states that he has been ill two months before he came into hospi- 
tal, and acknowledges that his illness was the result of long-continued 
habits of inebriety. Careless and intemperate in his mode of life, and 
frequently exposed to cold and wet, he got an attack of bronchitis, ac- 
companied by a sense of constriction about the chest, and difficulty in 
breathing. He was bled for this, and states that the bleeding relieved his 
dyspnoea ; but about this period he remarked that an anasarcous swelling 
appeared in his face, neck, and chest. 

In this case we have a specimen of the ordinary history of dropsy in 
this country : — first, intemperate habits, next, exposure to cold, followed 
by bronchitis or pneumonia, and then dropsy, commencing in the face, 
chest, and upper extremities. I have on a former occasion pointed out to 
the class the importance of observing in what part of the body the drop- 
sical swelling first appears, because, by doing so, we obtain a more accu- 
rate idea of its nature, and are furnished with a clue towards discovering 
its source. Dropsy is generally the consequence of organic disease of 
some deep-seated viscus. When it is produced by thoracic disease, as 
bronchitis, pneumonia, or affections of the heart, it is said that the swell- 
ing always begins in the face, neck, trunk, and upper extremities ; when 
it depends upon chronic hepatitis, disease of the spleen, obstruction of 
the system of the vena porta, or disease of the mesenteric glands, the 
swelling commences in the abdomen, and then proceeds to the lower ex- 
tremities ; but when it arises from mere debility, the consequence of hec- 
tic fever, long-continued diarrhoea, or a cachectic state of the system, the 
effusion is first observed in the lower extremities, coming on in the even- 
ing, and again disappearing towards morning. The history of dropsical 
swellings, therefore, by informing us in what part they first appeared, is 
often sufficient to indicate the general nature of the producing cause. 

When this man came into the hospital, his cough had disappeared, and 
there were not any unequivocal symptoms of disease of the heart, but he 
had considerable dropsical swelling of the face, chest, and superficial parts 
of the abdomen ; his appetite was bad, and on examining his urine, we 
found it loaded with albumen, and of the specific gravity of 1029. Though 
he had no fever or dyspnoea at the time, we commenced the treatment by 
general bleeding, because he was a person of rather robust constitution, 
and on account of his dropsy having originated in cold. In persons who 
are able to bear bleeding, and where the disease has commenced in an 
acute form, you may often commence the treatment of dropsy by a single 
bleeding with great advantage, even though there be no fever or local 
inflammation present. We next prescribed an aperient injection, to be 
followed by a vapour-bath. I then, by way of trial, gave him an elec- 
tuary containing some diaphoretic medicines, and found that it acted well 
on the skin, and that sweating could be easily induced. This furnished 
me with a key to the after-treatment. Whenever you find that sweating 



DROPSY IN ACUTE BRONCHITIS. 619 

can be easily brought on in dropsical cases, you should obey the hint 
given by nature. You should not, under such circumstances, have re- 
course to mercury, or hydragogue purgatives, or diuretics ; you are to 
open the passage which nature has pointed out, you are to encourage dia- 
phoresis, and you may rely upon it that you will in this way effect an 
easier, safer, and more permanent cure than you could by any of the 
various modes employed for similar purposes. We therefore gave this 
man a powder containing four grains of Dover's powder and five of 
nitrate of potash, three times a-day. The Dover's powder is tempered 
by combining it with nitrate of potash, which is an antiphlogistic, and 
prevents the former from exercising a heating effect on the system. Hav- 
ing continued these powders for seven or eight days, we commenced the 
exhibition of opium, in doses of half a grain, four times a-day, to be in- 
creased after a few days to half a grain every fourth hour. Under the 
use of vapour-baths used daily, and opium to the amount of three grains 
in the twenty-four hours, the man has improved wonderfully, and the 
dropsical swelling is fast subsiding. Opium has here, you may have re- 
marked, produced no bad effects. The tongue is neither dry nor furred, 
and it has not any of that appearance which is observed in persons who 
are in the habit of taking opium ; his appetite is unimpaired, his bowels 
regular, and his strength undiminished. 

Now, why did I give opium in this case ? The more advanced stu- 
dents will perceive, that I have treated it nearly in the same way as I 
treat cases of diabetes. There seems to be an analogy between chronic 
dropsy and diabetes, and experience has proved to me that this mode of 
treatment is most likely to be attended with success. I shall not dwell 
on this point at present, but shall content myself by referring to a paper 
in the second part of this work, observing here, that opium and other 
diaphoretics increase strength, remove the dropsical swelling, diminish 
the quantity of albumen in the urine, and bring on convalescence with- 
out producing any bad effects on the head or digestive system. I am 
anxious that you should attend to this case and watch the result ; for the 
treatment is quite different from that employed by others. I say this 
without meaning to claim any originality ; but I may be permitted to say, 
that it is a mode differing very much from those generally pursued. It 
cannot be used in cases where fever or local inflammation is present ; but 
when the local and general excitement has been subdued, or when the 
case is chronic and unaccompanied by quick pulse, or any symptoms of 
visceral inflammation, it may be employed with safety and advantage. 

The second case is that of the patient Matthew Gray, a man of middle 
age, and rather robust constitution. On admission, he stated that he had 
been dropsical for about twelve days, and complained of cough, dyspnoea, 
constriction of chest, and feverish symptoms. His cough was hard, short, 
and incessant, preventing sleep, and increased by every attempt at full 
inspiration. He had general wheezing, much oppression about the chest, 
and scanty expectoration of frothy mucus. His pulse was 84, soft and 
rather weak : he complained of nausea and loss of appetite, and had 
edema of the lower extremities. On examining the chest, I found it sound 
clear on percussion, and that the physical signs present were those of 
bronchitis passing into the stage of super-secretion. In addition to this, 
there were symptoms of engorgement in the lower and posterior parts of 
the lung. 



620 CLINICAL MEDICINE. 

Here, then, we had a case of dropsy supervening on acute bronchitis. 
I therefore ordered him to be blooded immediately, and afterwards to 
have cupping-glasses applied over the congested part of the lung. The 
local abstraction of blood was followed by remarkably good effects ; it 
relieved the cough and constriction of chest, and diminished materially 
the pulmonary congestion. I next prescribed the following mixture, of 
which he was directed to take one tablespoonful every hour : — 

R. Misturae amygdalarum, !|xij; 
Antimonii tartarizati granum, 
Nitratis potassae, £ij. 
Tincturae hyoscyami, giss. 
Tincturae digitalis, ^ss. 

A mixture like this is well adapted for such a case ; it removes the 
febrile condition of the system, and, by its demulcent and sedative proper- 
ties, allays the cough and bronchitic irritation at the same time that it de- 
termines to the kidneys. Those medicines which are termed demulcent, 
are frequently of great value in the treatment of bronchitis ; you will often 
derive more benefit from gum arabic, spermaceti, almond emulsion, and 
the like, than from any other class of remedies. In the present case, we 
combined them with sedatives and narcotics ; and as the remedies pre- 
scribed under such circumstances should be antiphlogistic, we added a 
grain of tartar emetic and two drachms of nitrate of potash. I have 
already spoken of the powerful antiphlogistic properties of a combination 
of tartar emetic and nitre, and dwelt on the benefits derived from it in 
many forms of inflammatory disease ; so that it is unnecessary for me to 
say any thing at present on the subject. It is obvious to all, that the 
tinctures were added on account of their sedative and narcotic properties, 
tending to remove irritation and induce sleep, of the want of which the 
patient complained. But you may ask me, why I did not order opium : 
simply because the disease was in its acute stage, and at a period when 
opium is apt to produce excitement of the system, and aggravation of the 
local symptoms. Instead of opium, I gave hyoscyamus, which neither 
increases heat, produces headache, nor checks expectoration ; and to this 
was added digitalis, a narcotic possessed of considerable antiphlogistic 
properties. Of all the narcotics, digitalis may be given with the greatest 
safety in cases where antiphlogistic treatment is required. 

It is unnecessary for me to follow up this case through all its details. 
It will be sufficient to state, that by gradually changing the nature of the 
treatment as inflammation declined, and particularly by the proper em- 
ployment of powerful purgatives, I have succeeded in producing a rapid 
amendment in his symptoms. It may be, however, necessary to explain 
why I used purgatives, and in what way they were exhibited. In cases 
where extensive bronchitis has given rise to pulmonary engorgement and 
dropsy, when you have relieved the acute symptoms by bleeding, leeches, 
or cupping, and other antiphlogistic means, and when there only remain 
some wheezing, oppression of the chest, and rather copious expectoration, 
you will often effect a vast deal of good by the judicious employment of 
powerful purgatives. You will clear the chest, relieve the breathing, and 
diminish the dropsical effusion. In the present instance, the patient took 
the following bolus : — 



TREATMENT OF DROPSY. 621 

R. Pulv. jalapae — rhei — scammoniae, aa. gr. v. 
Elaterii, gr. 86. 

Bitartratis potassae — sulphatis potassae, aa ^sb. 
Syrupi zingiberis, q. s., ut fiat bolus. 

This acted powerfully, and its operation was followed by marked dimi- 
nution of the pulmonary engorgement and dropsical swelling. I have 
frequently endeavoured to impress upon the class the truth of an observa- 
tion made by Dr. Paris, that in the exhibition of remedies, much better 
effects are obtained by combining several analogous remedies in small 
quantities, than by giving a single one in a large dose. By combining 
substances which are of the same nature, that is to say, which are indi- 
vidually capable of exerting the same effect on the system, we are capable 
of producing more decided effects, even though these substances be given 
in diminished quantity, than if we prescribed any one ingredient of the 
combination in a full dose. I refer to this general principle, in order to 
explain why I had recourse to so many different medicines, instead of 
employing a single powerful ingredient in considerable quantity. It ex- 
plains why, instead of giving at once fifteen grains of the powder of jalap, 
I gave five grains of jalap, five of rhubarb, and five of scammony, and 
added to these half a grain of elaterium, and a small quantity of cream of 
tartar and sulphate of potass. With respect to elaterium, I may observe, 
that it has been strongly recommended in those cases of dropsy where 
there is no irritation of the digestive system present. Its action on the 
intestinal tube is very energetic, and from the quantity of watery secretion 
which it generally brings away, it is of great utility in removing anasar- 
cous swellings. 

These are the principal observations which I have to offer with respect 
to this case. I may mention, that as the patient complained much of 
restlessness, we prescribed half a grain of morphia, to be taken at bed- 
time. This succeeded in producing sleep, a most important point in the 
treatment of all acute affections. We have now omitted the use of the 
more powerful remedies, and have prescribed to-day a decoction of Ice- 
land moss, with tincture of opium, to act as a pectoral demulcent, and he 
has been allowed chicken-broth and jelly. He is going on at present 
in a very satisfactory way, but it will be necessary to watch him care- 
fully during his convalescence, and obviate the occurrence of a relapse. 
If discharged at present, and before convalescence is perfectly established, 
he would in all probability relapse, and soon become much worse than 
ever. Hence I intend to keep him here for a month or six weeks. As 
long as I have been attached to public hospitals, I have made it a fixed 
rule, in all cases where a cure was possible, to keep the patient until it 
was confirmed. Whenever 1 was obliged, under the pressure of urgent 
necessity, to dismiss a case before healthy action was completely re-estab- 
lished ; or whenever patients left the hospital prematurely of their own 
accord, I have observed that such persons, particularly if placed in the 
lower ranks of life, and subject to the numberless accidents and exposures 
of poverty, almost invariably returned in a far worse condition than be- 
fore. It is much better, though perhaps it does not make so striking an 
appearance in hospital returns, that a certain number of patients should 
receive all the benefits derivable from such institutions, than that a greater 
number should pass through them in the year, and be hurried out of them in 
a state of imperfect convalescence. This observation particularly applies 



622 CLINICAL MEDICINE. 

to fever hospitals, and is, I fear, too little attended to in this city. Cer- 
tain I am, that a vast number of the cases of incurable pulmonary and 
intestinal disease which are admitted annually into the Meath Hospital, 
have had their origin during the state of debility in which the patients 
were then dismissed from a fever hospital. Improper diet, imperfect 
clothing, bad lodging, damp rooms, are borne by the constitutions of the 
poor with comparative impunity as long as they are in a state of health ; 
but not so when they are debilitated by a recent attack of fever, treated 
or maltreated by active remedies, and dismissed from hospital in a week 
or ten days after the crisis has taken place. How injurious to persons so 
debilitated the change from the warmth and comfort of a hospital to the 
cold and desolation of a damp garret or cellar ! Add to this, that many 
of them, at the time of their discharge, still evidently bear the marks of 
mercurial action in their system, and many have their hair very short, in 
consequence of the head having been shaved during their illness. Hence 
many catch colds that affect the ears or eyes; many become deaf, and not 
a few get sore eyes ; while the number of those in whom the sequela? of 
the fever rapidly induce incurable chronic diseases is so great, that, were 
the balance of the account to be fairly struck out, it would be found fever 
hospitals do less good to the public health than is generally imagined. 

A patient who is at present in the chronic ward presents- some circum- 
stances worthy of observation, as connected with peculiar varieties in the 
alvine discharge. She has been labouring for some time under melsena, 
and, as you have observed, passes daily a large quantity of dejections 
from her bowels, as black as ink. The colour of matters discharged from 
the bowels is subject to very great variety. In some cases they are clay- 
coloured or whitish, somewhat like barm ; and I have seen them still 
whiter, and approaching the hue of milk. It is in cases of the latter kind, 
where the discharges are of a milky appearance, that persons have been 
said to pass chyle, and their emaciation has been attributed to a deficiency 
of nutriment depending on this cause. This, however, is not the fact : 
in some cases of chronic dysentery and diarrhoea, a fluid whitish discharge 
takes place from the rectum, but this is not chyle, it is only the changed 
mucous secretion of the irritated portion of the bowel. It is very curious 
to observe what different products the same set of secreting vessels will 
give rise to, according to the mode in which their vital action is affected. 

In other cases the discharges from the bowels consist of fatty matter, 
which bears a strong resemblance to wax, or adipocire. Again, we may 
have them of a very dark, or even black colour. I have seen the stools 
quite black in particular forms of dyspepsia. Some time ago I attended 
a gentleman at Drumcondra, who exhibited this change in the colour of 
the intestinal secretions to a very remarkable degree. He was a very 
large man, accustomed to eat and drink very heartily, having, no doubt, 
a very capacious stomach and bowels, and a great quantity of fluids and 
solids. I mention this in order to give some explanation of the enormous 
quantities of this black fluid which he passed by stool and vomiting. 
After complaining for a considerable time of dyspeptic symptoms, he got 
an attack of vomiting ; and as he drank freely of diluents during the act 
of emesis, the quantity of this black fluid which he threw up was amazing ; 
indeed, I might say, without exaggeration, that he vomited by the gallon. 
With this he had eructations of sulphureted hydrogen to such an extent, 
that it was almost impossible to remain in the same room with him. His 



PECULIAR ALVINE DISCHARGES — MEL.ENA. 623 

tongue was as black as ink, and though frequently cleansed, resumed in 
a short time its former hue. He also passed an enormous quantity of the 
same stuff by stool. This matter I ascertained, by numerous observations 
and experiments, to be a secretion from the mucous membrane of the 
bowels, and not depraved bile, or blood changed by the acid secretions 
of the bowels. Black stools may also depend upon the presence of other 
matters, as in cases of melapna. Melaena consists of a discharge of gru- 
mous blood from the intestines, either with or without black matter. The 
following is the way in which it occurs : Blood is secreted slowly into 
the intestinal tube ; while it remains there it is acted on by the acid secre- 
tions of the intestines, the effect of which is to change the colouring mat- 
ter into a black, and in this state it is passed by stool.* Again, there are 
other cases in which the discharges from the bowels are found of a tarry 
and viscid consistence, and having a greenish-black appearance : this 
would appear to be connected with a vitiated state of the biliary secre- 
tion. 

I have spoken here of three species of black discharge, each of a dif- 
ferent kind, and requiring to have a distinction made between them for 
practical purposes. Now it is said, if blood be present you can easily re- 
cognise it by putting a portion of the discharge inclosed in a small linen 
bag, into warm water, when, after remaining some time, the linen will 
be stained of a reddish colour. If you take a portion of the tarry dis- 
charge, and drop a little of it into water, it will communicate to it a yel- 
lowish stain. On the other hand, the black fluid, which consists of 
vitiated mucous secretion, will not impart either a red or yellow tinge. 

I may further observe, that various substances used medicinally com- 
municate a particular tinge to the alvine discharges. Thus acetate of 
lead, when it meets with sulphureted hydrogen in the intestines, changes 
the stools to a black colour. Again, many of the salts of iron have the 
same property. Other substances, such as logwood, bilberries, &c, im- 
part to them a red tinge, while the continued use of chalk-mixture is apt 
to render them whitish or of the colour of pipe-clay. This is apt to give 
rise to suspicions of the existence of obstruction of the liver; and in one 
instance I was deceived for some time by it myself. With respect to the 
greenish-coloured discharges, they are those which are most frequently 
met with, particularly in children, and are therefore entitled to a greater 
degree of consideration. There is nothing more common than to meet 
with cases of this green discharge during the period of infancy ; and I 
regret to state that a great deal of error has prevailed on the subject. 
Greenish stools are generally looked upon as a sign that the child's liver 
is out of order, and as an indication for giving calomel. This, however, 
is by no means true; they not unfrequently depend upon irritation of the 
intestinal mucous membrane approaching to inflammation. The proper 
mode of treatment here consists in adopting measures calculated to remove 
irritability. In such cases, warm baths, the application of rubefacient 
liniments to the abdomen, the use of antacids, such as chalk-mixture, the 
carbonates of soda and ammonia, small doses of laudanum, and hydrarg. 

"* The blood effused in melaena, coagulates in the bowels, and being exposed to heat and 
air, turns black, and often becomes fetid. When retained very long, the colouring matter 
may be washed away, and the coagulated fibrin left. In a dissection of a woman who died of 
melaena, at Berlin, I found in the large intestines many hard balls, the size of apples, and con- 
sisting- of fibrin, deposited in concentric layers, evidently the result of successive separations 
from the blood, effused during several different attacks. 



624 CLINICAL MEDICINE. 

c. creta with Dover's powder, form the best remedies ; and their opera- 
tion will be very much assisted by a careful attention to diet. You will 
sometimes, it is true, meet with greenish discharges in adults, but then 
they are not so fluid as those of children, nor are they attended with the 
same irritability of the gastro-intestinal mucous membrane. Here the 
best plan of treatment is the Abernethian : blue pill at night, and a mild 
aperient in the morning, will be sufficient to correct the intestinal derange- 
ment, particularly if assisted by a well-regulated diet, and exercise in the 
open air. But in children the greenish discharge is often of a much more 
acute character, and more closely allied to inflammation, or rather irrita- 
tion ; although in some cases it may go on for a considerable time with- 
out producing any acute disorganization. It is on account of the property 
which calomel and other mercurials, exhibited internally, possess of caus- 
ing irritation in the first instance, and if pushed farther, inflammation of 
the mucous membrane of the intestines, that they are also apt to produce 
discharges from the bowels, copious, fluid, and mixed with green mucous 
flocculi, resembling closely chopped spinach. Sometimes the dejections 
consist of this green mucus nearly unmixed with any thing else, and 
then they appear like semi-fluid boiled spinach. Now most practitioners 
think that this green colour is derived from bile which the mercurial has 
brought down in unusually great quantities from the liver, excited to a 
more energetic act of secretion. It has nothing to do with the bile in 
many cases, but is entirely derived from the irritated membrane of the 
intestines. Long ago I pointed out, and was the first to point out, this 
fact, in the Dublin Hospital Reports. It has very important practical 
bearings. 



CLINICAL LECTURES 



BY W. W. GERHARD, M.D. 



41 



CLINICAL LECTURES. 



LECTURE I. 

Acute articular rheumatism — Connection with inflammation of the cardiac membranes — 
Treatment, bleeding, opiates, &c. 

I shall to-day, gentlemen, take up the subject of acute articular rheuma- 
tism, as it is especially prevalent at this season of the year, when the 
number of other acute diseases is very limited. In summer we have 
acute abdominal inflammations, and in winter affections of the pulmonary 
organs, while, during the spring and early summer months, serous inflam- 
mations, both of the internal and external membranes, are most common. 
Acute rheumatism bears some striking relations with the inflammations of 
internal serous membranes, from the similarity of the mode of treatment 
which often becomes necessary in both affections, and from the frequent 
complication of the latter with the former disease. In almost every severe 
case of rheumatism under notice, there co-exists inflammation of the 
covering of the heart, or of the serous membrane lining its cavities. Since 
this connection between the pathology of articular rheumatism and that of 
diseases of the heart and its membranes, has been clearly traced, the dis- 
ease has attracted much interest. I say clearly traced, for the general 
fact had been long since pointed out, although the subject was not pre- 
cisely understood. That is, it was in the same situation as many other 
parts of pathology ; affording an indistinct view of the truth, but without 
that well-defined character which is now required, according to the rules 
of rigid logic which we endeavour to apply to the study of pathology. 
The line of connection has only been drawn in a definite manner, for a 
few years past, between acute articular rheumatism, and endocarditis, or 
inflammation of the lining membrane of the cavities of the heart, and peri- 
carditis, or inflammation of the membrane surrounding it. Dr. Bouillaud, 
of Paris, has paid particular attention to this subject ; he tells us that at 
least one-half the acute articular rheumatic affections are complicated with 
pericarditis. In this estimate he is probably wrong, unless with pericar- 
ditis we are permitted to include endocarditis. A large number of mild 
cases doubtless run their course, without any complication of the kind, 
but it is usually otherwise when the disease appears under a severe type, 
and we might say that many more than half the severe cases, probably 
two-thirds, are complicated with some inflammation of the heart. Of the 
other third, a large portion present signs of some functional disturbance, 
though not of positive inflammation. Mild cases are slow T in their action 
upon the heart, but, in the severer forms, the advance is rapid, and dis- 
ease of the heart succeeds almost immediately after the first appearance of 
the articular symptoms, la chronic cases, the progress of the cardiac 



628 GERHARD'S CLINICAL LECTURES. 

affections is slow, and an individual not well acquainted with the disease 
might be deceived as to their existence. 

We have thus traced two forms of the disease, and I propose bringing 
under your notice two cases now under treatment in the Philadelphia 
Hospital, to exemplify them. 

The first is that of John Robb, who was admitted into the ward No. 2, 
on the 11th of April. Previous to his admission, he had been ill but a 
short time ; being an inmate of the Aims-House, he was able to resort to 
medical assistance quite as soon as is usual in private practice. He had 
been working on the farm of the establishment for eight months previous 
to his attack, and had enjoyed good health. On the morning of the sixth, 
he complained of slight pains in his shoulder, but continued at work ; at 
eleven, p.m., he was taken with severe pain in the hip, which lasted four 
or five hours, and then, diminishing in the hip, went to the knee. On 
the seventh it ceased in the right knee and attacked the left. 

Now, from the character of the affection, thus shown, we can, without 
going farther, make our diagnosis. I allude to its metastatic character, 
as exhibited in its leaving one joint and settling in another. This is 
almost distinctive of rheumatism. 

There was no pain in the ankles, but there was slight pain near the 
toe. You here mark the course of the disease onwards ; it has reached 
the toe, and shows a disposition to attack the whole foot. There had 
been pain in the right wrist, from an hour before the man's entrance into 
the hospital. On the ninth and tenth, he had pain in the breast, which 
he referred to a spot below the prsecordia, in the region of the diaphragm, 
and which lasted twenty-four hours, and was increased by coughing. 
Such pain is usually owing to disease of the heart, which may be merely 
muscular, but it is more frequently caused by inflammation of the serous 
membranes lining or covering the heart. 

This man had been exposed to no causes of disease other than those 
which he was in the habit of encountering. He had, it is true, been wet 
while working on the farm, but this was not uncommon with him : he 
had been long accustomed to working in the rain. This shows how cau- 
tious we should be in admitting causes of disease ; some physicians might 
be disposed to attribute the attack of rheumatism to the last wetting, 
which could manifestly exercise no greater influence upon the man than a 
series of previous exposures to the same cause, of no recent occurrence. 
I look upon the particular season of the year as the principal excitant of 
the disease, and it is for this reason that I have thought it a fitting subject 
to bring before you at the opening of my course. If you take the trouble 
to inquire, you will find that at this time the prevalence of rheumatism 
and rheumatic pains is remarkable. But an accidental exposure will often 
develop what might otherwise have remained dormant, and thus the dis- 
ease, like many others, must be referred to two different causes, a general 
and an accidental one. The influence of the former is in this case much 
greater than that of the latter. 

The case before you being of an acute character, its previous history 
is not nearly so important as the present state of the individual. It is 
otherwise in chronic affections, in which the whole anterior history is all- 
important. 

The condition of the patient at the time of his admission on the eleventh, 
was as follows. The face was slightly flushed, and presented an expres- 



ACUTE RHEUMATISM. 629 

sionofpain. This pain in acute rheumatism, is remarkable; it usually 
prevents all exercise, and confines the patient to bed. 

There was slight soreness in the shoulder, but without swelling or 
heat; no pain or swelling in the left arm, slight soreness in the right 
elbow, and severe pain, swelling, and heat in the wrist. The same pain, 
swelling, and heat extended to all the joints of the hand and fingers, 
excepting the thumb. There was some pain in both knees, especially in 
the left ; none in the ankles ; a little in the right hip, no tenderness of the 
spine, no cephalalgia ; tenderness on pressure along the region of the 
ribs ; this was probably the remains of the diaphragmatic pleurisy. The 
impulse of the heart was feeble, the second sound nearly lost, the first 
much roughened, dulness on percussion nearly natural. Treatment, one 
grain of opium every four hours. The digestive organs were healthy. 

Now, let us analyze this case. The first fact worth recollecting is the 
absence of tenderness of the spine. This establishes the diagnosis between 
simple rheumatism and that which is allied to neuralgia. Hence, the 
mode of treatment which proves so excellent in the latter affection may 
here fail. The state of the heart indicated merely slight valvular disease, 
and some muscular impediment ; there was no effusion, the dulness on 
percussion being natural, and no creaking sound being heard. 

The treatment in this case was after a plan of practice in New England, 
from which quarter it has been lately strongly recommended ; the internal 
administration of opiates, pushed till felt by the patient. 

During the twelfth, six pills of opium containing each a grain, were 
exhibited, but there was no diminution of pain. Neither sleep nor cepha- 
lalgia had been induced by the opium. This is an important therapeutic 
point, demonstrating the antagonising action which pain exerts in regard 
to the effects of opium. The first sound of the heart was still rough, but 
the impulse rather less ; no increase of flatness. The state of the heart 
was, therefore, slightly improved. Pulse eighty-four, of moderate size 
and regular ; a grain of opium was ordered every two hours, and a laxa- 
tive enema administered. 

On the evening of this day there was some cephalalgia, although no 
deviation of the pupils from the natural state. The dose of opium was 
diminished to a grain every three hours. Sleep was interrupted by 
twinges of pain ; sweating at night. Eruption of sudamina ; pulse 
seventy-two ; pain in right arm increased and extending to the shoulder. 
Less pain and swelling in the knees, but increase of both in the feet. 
The action of the heart was more regular and feeble, and the sound less 
rough. The disease, you perceive, was not in any manner arrested, 
although you note a decided improvement in the condition of the heart. 
There was costiveness from the opium, but this, you will soon see, disap- 
peared. Same prescription of opium continued during the thirteenth ; 
hop poultices to most of the painful joints ; laxative enema. 

On the fourteenth, the pain having diminished throughout the right 
arm, began in the left hand and wrist. Here is another point of interest ; 
the translation of the pain from the right to the left limb by metastasis. 
This is a common thing in articular rheumatism, and, as in this case, the 
pain does not usually quite cease in one joint before it begins in the 
other. 

There was slight pain between the shoulders, and diminution of the 
pain in the knees and feet ; pulse seventy-six, fuller and regular ; this is 



630 GERHARD'S CLINICAL LECTURES. 

somewhat an exception to its usual condition in the disease, it being 
generally frequent, small, and tense. Skin warm and dry ; sleep very 
irregular ; tongue moist, with a yellowish coat ; appetite bad ; thirst ; 
three or four stools since the enema ; the opium had, therefore, induced 
no costiveness. No cephalalgia or dizziness ; slight flush ; eyes natural. 
Opium continued, hop poultice and laudanum to the left wrist. 

On the fifteenth, the left hand was worse, and there was pain in the 
sole of the right foot. The other pains were better, moisture rather than 
sweating. Opium continued. 

The sixteenth, less expression of pain, and less flush ; soreness in both 
shoulders, with slight swelling, but not much constant pain. Slight sore- 
ness of the left elbow ; much swelling, pain, and heat of the left hand ; 
right hand nearly free from swelling, still slightly painful, but motion 
returned ; pains much diminished in the legs ; pain at the ensiform carti- 
lage ; palpitations frequent after slight exertions ; pulse seventy-two, and 
soft ; decided roughness, almost rasping, in the first sound of the heart, 
which was not very loud, and heard most distinctly to the left of the 
nipple, second sound nearly lost. Under the sternum, both sounds of 
the right side distinctly heard and clear, the first only a little roughened. 
The precordial dulness commenced only at the left margin of the sternum, 
and extended to the nipple. The morbid alteration was, therefore, con- 
fined to the left side of the heart, implicating the valves - y there was besides 
effusion into the pericardium. The opium pills were continued during 
yesterday and last night every three hours. Hop poultices. 

Last night the pupils were somewhat contracted, and little sensible to 
the light. To-day the face was flushed, and presented an expression of 
stupor. Disposition to sleep ; pupils rather large ; no cephalalgia ; sleep 
interrupted by pain, shooting from the swollen joints. Pulse eighty-eight 
— softer. Swelling less marked in the left hand. Slight swelling and 
pain in both knees. No pain in the breast. Impulse of the heart almost 
lost ; both sounds very feeble, without roughness. The disease of the 
valves is therefore diminished. Percussion slightly dull at the upper por- 
tion of the left side ; flat, down from the third rib to the same extent as 
yesterday. Prominence obviously increased. These latter signs are ex- 
plained by the increased effusion into the pericardium. Still slight diar- 
rhoea ; three or four stools in the twenty-four hours. Skin moist, without 
sweating. A grain of opium every four hours. 

This case, gentlemen, of acute disease of the heart, occurring in the 
course and as a direct consequence of acute articular rheumatism, may 
serve as a type of the affection, which I shall now make the subject of 
some general remarks, and have occasion to refer to hereafter. There 
are several peculiarities to be alluded to. In the first place, the change- 
able character of the affection, shifting, as you have seen it, from joint to 
joint, denotes the nature of the disease. This is well understood, and 
universally admitted. But I would have you remark that there was no 
metastasis to the heart. The disease of the heart appeared, during the 
most acute stage of the rheumatic fever, which afterwards continued with 
unabated severity. This is almost always the case : cases of metastasis 
are quite exceptional, and the cardiac inflammation is not only most fre- 
quent, but is also most severe during the height of the articular inflamma- 
tion. By physical examination, we ascertained that the pain in the 
precordial region proceeded first, from disease of the valves, indicated 



ACUTE RHEUxMATJSM. 631 

by the roughness of the sound ; secondly, from effusion, shown by the 
unnatural dulness on percussion, imperfect action of the heart, &c. 

Another symptom to be noticed is the sweating, which was very slight 
from the first or second day, although it is generally very profuse in acute 
rheumatism. It is this sweating in rheumatism which has suggested the 
employment of Dover's powder, and other sudorifics, in its treatment. In 
this case opium was alone resorted to, to afford a better test of the powers 
of the remedy. 

The diarrhoea is another feature worth remarking, co-existing, as it did, 
with the large doses of opium. It was a purely accidental complication, 
but its occurrence demonstrates that opium, in very large doses, continued 
for some time, and given much in the same way as the large, doses of 
tartar emetic are by the contra-stimulants, does not produce the same 
effects as in ordinary doses, thus illustrating a therapeutic law, that reme- 
dies, in over-doses, do not act upon the system in the same manner as 
when administered in the usual quantities. Were it not for this law, pa- 
tients would die from the action of certain remedies now frequently pre- 
scribed. How could tartar emetic be given in the high doses required 
by the contra-stimulant practice in pneumonia, or calomel, as it is pre- 
scribed in the diseases of certain sections of our country ? 

The pathology of the disease under consideration is still very obscure, 
although its symptoms are well understood. How much of the disease is 
allied to neuralgia, or connected with an affection of the nervous system, 
and how much belongs to local inflammation, are points that are still un- 
settled. It is, in this respect, analogous to hooping-cough, and some 
other diseases. We are also embarrassed as to effectual curative means 
for arresting the progress of the affection, though we have any number of 
palliatives. For the present I refrain from entering largely into the patho- 
logy of rheumatism, but shall consider it partly as nervous and partly as 
inflammatory in its character. Certain inflammations of internal organs 
which occur in rheumatism, such as pericarditis, lose this mixed charac- 
ter, and become decided phlegmasia? ; they are accordingly treated with- 
out reference to disease of the joints. When the complication of pericar- 
ditis proves fatal, and the opportunity, otherwise rare, of examining per- 
sons who die with rheumatism, is obtained, there is often almost a total 
absence of lesion in the joints ; but the pericarditis offers the same anato- 
mical lesions, as if it had been induced by exposure to cold, or injury, or 
some other ordinary cause. The affection of the joints depends so much 
on a nervous cause, that it presents very slight traces of inflammation. It 
seldom or never terminates in suppuration, or the other usual terminations 
of inflammation. Dr. Chorael states, that pus is not found in rheumatic 
joints; the very rare cases in which it is met with, he considers to be 
mere accidental complications. This opinion, if somewhat modified, is 
probably the correct one ; that is, rheumatic differs from ordinary inflam- 
mation in the absence of pus, and its want of fixedness of position ; but 
ordinary local inflammation may ensue and constitute a complication. 
Not so with the accompanying internal inflammations ; they result in the 
secretion of pus, and effusion of lymph, and are fixed in their location. 

If the pathology of the disease is obscure, equally so is the therapeutics, 
it being more than doubtful whether we possess any settled or absolute 
method of treatment. This subject is very clear, no doubt, to some 
authors ; but, unfortunately, practitioners generally are in the dark. Thus 



632 GERHARD'S CLINICAL LECTURES. 

Bouillaud, who regards the affection as merely inflammatory, depletes to 
the utmost possible extent ; and for this exaggerated depletory practice 
claims great success. His success may have been great, but others who 
have followed the practice, perhaps without the same enthusiastic confi- 
dence, have not been so fortunate. I have given the practice a very fair 
trial, with every disposition to see it succeed, and, although I have 
afforded relief by one or two moderate bleedings, if persisted in, the result 
was unfavourable ; if pericarditis were present, it was only partially re- 
lieved, while the rheumatic affection of the muscular substance of the heart 
often increased. Besides, the ulterior results of excessive blood-letting are 
generally mischievous. We thus merely return to the old practice of one 
or two bleedings at the commencement of the affection ; a practice^ the 
utility of which is sanctioned by long experience. 

Another practice, originating, I believe, in New England, and recom- 
mended by Dr. Webb, of Providence, is that which has been followed in 
the present case — consisting in the administration of very large doses of 
opium. I have tried it in two cases, in both of which it failed. It 
succeeded in stupifying the patient, and rendered him less sensible of 
pain, but produced no decided impression on the disease. It did not 
prevent the change of place, nor did it remove the pain or swelling. 
These symptoms persisted, and retained their usual mutability of cha- 
racter. Last summer, I pushed the remedy to such an extent as to induce 
decided narcotism, yet I failed to cut short the disease. The remedy 
may occasionally obtain the success which is claimed for it, but it is 
clearly no specific. 

Sudorifics constitute the treatment adopted by some, from a notion that 
artificial sweating is but an imitation of the curative process of nature. 
This is certainly not the case ; for the sweating is often profuse, while the 
violence of the disease is persisting. If, however, the discharge be sup- 
pressed, from cold or any other cause, it will be proper to resort to sudo- 
rifics, to revive this natural secretion, and restore to the patient what he 
has been deprived of; for in such cases the suppression of sweat is cer- 
tainly productive of harm, and increases the suffering of the patient. 

Other remedies have been recommended, as narcotics and purgatives, 
particularly the colchicum, and, what is analogous to it, the veratria. 
The colchicum is used in this country and in England, but it is not 
much employed in France. It is very useful as a palliative, though far 
from being absolutely curative. I have seen it stop the severer symptoms 
of the disease, for as much as five or six successive days, without curing 
the disorder. I often use it at the hospital without other medicines, pre- 
ferring, as I do, the administration of simple remedies, particularly in 
hospital practice, to insure their accuracy of administration, and to enable 
us to judge of their effects. By giving the wine of the roots or seeds, 
alone, we may avoid the severe purgation resulting from Scudamore's 
mixture ; but purging may be of service, if the patient can readily bear 
the motion necessary for the evacuation of the bowels. But the disad- 
vantage attending frequent rising is apt to more than destroy the good 
arising from the revulsive effects of the purging. In medicine, as well 
as in surgery, inflamed parts must be kept at rest. 

In general, however, it is better to combine the colchicum with some 
opiate, as laudanum or black drop ; in doses of half a drachm of the wine 
of the seeds, or even more if tolerated by the patient, and ten to twenty 



ACUTE RHEUMATISM. 633 

drops of laudanum every two, three, or four hours. The preparations of 
colchicum are so irregular in strength that it is very difficult to state these 
with precision. A slight impression upon the stomach and bowels is the 
best guide. 

These views, as to the effects of remedial agents in rheumatism, differ 
but little from those of Dr. Chomel, who, perhaps, has more than a due 
share of skepticism in relation to therapeutics. It is true, however, that 
when diseases, after running a certain course, get well of themselves, they 
are apt to deceive us as to the value of the remedies employed in treating 
them. This, I think, is the case with Drs. Bouillaud and Webb. For 
the opinions of the former of these physicians on this subject, I refer you 
to Bell's Select Medical Library (1837) ; and for Dr. Webb's, to the Boston 
Medical and Surgical Journal, for last year. 

I am not disposed to enter into a history of all the different forms of 
treatment which have been recommended in rheumatism. Of external 
applications, cups to the spine, as a counter-irritant, is a most valuable 
palliative ; and, if the neuralgic element of the disease predominate, 
cupping along the spine will sometimes produce a real arrest of rheuma- 
tism. But when the joints are the principal seat of the disease, in most 
cases much is not to be expected from cups or leeches to the spine ; they 
do better near the joints. Other applications to the parts are directed for 
the benefit of moisture and warmth. For this purpose, anodyne poultices 
are useful ; none is better than one of hops, steeped in hot water, or 
vinegar and water, sprinkled with a little laudanum. These are very 
convenient applications, but cannot be accommodated to all the joints. 
Opiate frictions may be used, such as a mixture of warm oil and laudanum. 
I refrain from lead-water, or spirituous, or other stimulating embrocations, 
as the danger of the internal affection, endocarditis, or pericarditis, is 
somewhat increased by driving the affection from the joint. This prac- 
tice must be reserved for the sub-acute variety of the disease. 

Other local applications of a soothing character may be resorted to, 
such as the experience of every practitioner will suggest. In the North, 
there are other remedies, the virtues of which are much extolled, such as 
the green hellebore, actsea racemosa, &c. These plants have been tried 
here, but without the success which is claimed for them. This want of 
success may depend on our obtaining them only in the dry state, in which 
their virtues are impaired. But I cannot believe that this is the sole 
cause of failure ; for the most decided action of the remedies will some- 
times be produced without curing the rheumatism. 

Though not immediately dangerous, few affections are ultimately more 
mischievous than acute rheumatism. Diseases of the heart are so apt to 
originate with it, and to continue after its cessation, that we must hail any 
plan of treatment likely to exercise a curative influence over it. I have 
therefore tested the opiate practice, as the last which has been recom- 
mended, watching very carefully its effects. I certainly pushed it as far 
as was prudent ; I was not warranted in giving more than one grain 
every two hours, particularly as I could not see the patient after each 
dose, a precaution which is always advisable when giving high doses of 
opium. 

In other cases of the disease, I am willing to try other modes of treat- 
ment which are highly recommended, although I fear that they are all 
merely palliative, and as such only may do good ; at last, we may find 



634 GERHARD'S CLINICAL LECTURES. 

some one more efficacious than the others. I am doubtful as to the im- 
mediate success, though strong in hope. I cannot help agreeing with 
Chomel, skeptical as he is generally, in believing inflammatory rheuma- 
tism an affection not to be cut short by remedies, after having seen so 
much protracted suffering from it ; even in the case of physicians them- 
selves, treated under the most favourable circumstances, it has been pro- 
longed to four or five weeks and upwards. 

What is the natural duration of acute rheumatism ? It is not precisely 
fixed, but is scarcely ever less than two weeks, and may last for five or 
six months ; at least, the immediate effects may continue so long. Like 
most diseases that run a determined course, it averages two or three 
weeks. 

Although I do not believe that in most cases it can be suddenly cut 
short after the pain and swelling of the joints are considerable, yet an ap- 
propriate treatment is useful as a palliative, and diminishes the mischie- 
vous results. In a few words, the treatment which I would recommend 
consists in one or two general bleedings, opiates combined with tartarized 
antimony or colchicum, and if the pain be very severe, local depletion is 
useful for those joints which are nearly in the state of ordinary acute or 
chronic inflammation. Purging and other remedies are directed when 
specially indicated. This of course is a mere outline of treatment, which 
requires frequent modification. 

Of the second patient whom I mentioned, my time will allow me to say 
little or nothing. He offers signs of disease of the heart different from 
those of the last, chronic dilatation and slight hypertrophy, without dis- 
ease of the valves, the sounds not being at all roughened. There is effu- 
sion into the pericardium, indicated by increased dulness on percussion. 
Further details I reserve for another occasion. 



LECTURE II. 

Continuation of acute rheumatism — Rubeola, or measles, in adults and children — Symptoms 
- — Complications — Treatment. 

I will again call your attention to the case of the man Robb, who was 
under notice as subject to acute articular rheumatism. The opiate prac- 
tice had been carried out with decided but gradual improvement. Yes- 
terday, however, there was a return of the affection, but under a much 
less severe type, marking the stage following the acute form of the disease, 
in which the symptoms are swelling and mere soreness, rather than pain 
or heat. With the reappearance of the affection in this modified shape, 
the impulse of the heart, which had been increasing, has been for two 
days much diminished. There is at present an effusion of about a pint 
of liquid into the pericardium. The dulness on percussion is so manifest 
as to leave no doubt of this fact. It is not from the simple presence of 
unusual dulness, that we draw our conclusion, but because we have seen 
this dulness notably increase, from day to day, since the patient has been 
under inspection. A prominence of the chest over the region of the heart 
has also appeared, in a marked manner, during this time. Another proof 






MEASLES. 635 



f the effusion is the absence of the impulse of the heart, which is next to 
lothing. You recollect the roughness of the two sounds of the heart, par- 
icularly the first; this roughness has diminished as effusion has gone on. 
n proportion, then, as the pericarditis advanced towards secretion, have 
the signs of endocarditis become less evident. This fact, which exem- 
plifies a general rule of pathology, is worth recollecting. Of pericarditis 
the physical signs are, mainly, the increase of prominence and dulness 
with faintness of the impulse of the heart, while endocarditis is to be re- 
cognised by increased action of the organ, and the roughened sound, 
sometimes amounting to that termed rasping. The physical signs of these 
two affections, particularly of pericarditis, are exceedingly easy of recog- 
nition, so much so, that, knowing what they are, you will hardly fail to 
detect them. The two diseases are not likely, I have told you, to e\\<t 
together under an equally severe type. The same thing is true of pleu- 
risy and pneumonia ; they may coexist, but very severe pleurisy and 
pneumonia do not go together. If, for example, the pleurisy be aggra- 
vated by the compression of the lung, it impedes the development of 
acute inflammation. The law of pathology, founded on the two cases I 
have adduced, you will find generally to hold good. I shall here con- 
clude my remarks on the case of rheumatism : the opiate practice was 
continued till yesterday, when it was modified by the substitution of a 
single dose of Dover's powder at night, in place of the opium pills. 

It is my intention in this course of lectures, gentlemen, to take up the 
various acute diseases in succession, as they come before our notice, at 
the hospital, preserving, as far as possible, the natural connection amongst 
them. A very unusual affection in general hospital practice has tat 
claimed your attention, I mean rubeola. To see it pervading epidemically 
the wards of adults is a phenomenon which I have never before witne^ 
and hardly expect again to observe ; as it is a disease which usually ap- 
pears but once during life, and is generally confined to childhood. Dur- 
ing the last six weeks, however, there have been as many as seven or 
eight cases in my single service, and three or four in the other wards. 
My recent cases were as follows : 

Morris, a man of nearly forty ; Perry, a lad of eighteen, and three 
others of nearly the same age. 

Previous to detailing the symptoms which characterize rubeola, I shall 
make a few remarks on its pathology. The pathology of measles, like 
that of other exanthematous affections, is to be divided into two parts, 
one comprising the morbid changes in the body, which are characteristic 
of and essential to the disease, the other being those which are merely 
accidental. The first are of course to be looked on as pathognomonic. 

The description of the affection given by Sydenham is so good, and 
agrees so accurately with its appearance at the present day, that I shall 
read it to you at length, and adopt it, in most particulars, in preference 
to modern accounts. It cannot be amended materially, except by exa- 
mining the symptoms with the aid of the numerical method ; a task 
which, at present, I am not able to undertake.* 

This excellent description of Sydenham's shows his powers of observa- 
tion in favourable contrast with some of modern times. His general 
account of the disease holds good in the cases which we observed at the 
hospital. Thus, our symptoms of the first day, like his, were chilliness 

* It was then read. 



636 GERHARD'S CLINICAL LECTURES. 

and cold shiverings. The second day we had the catarrhal symptoms, 
connected with coryza and the flow of tears, as described by Sydenham. 
This is the best sign to distinguish measles in its incipient stage from 
other exanthemata. In this stage, the other exanthematous affections 
offer no mark by which they can be diagnosticated with any certainty. 
They have, at this time, numerous symptoms in common, including some 
belonging to other febrile diseases. Thus, in scarlatina, the sore throat is 
by no means sufficiently characteristic, and small-pox may, at its com- 
mencement, be very readily mistaken for typhoid fever. Dr. Louis, who 
certainly is most accurately familiar with typhoid fever, has more than 
once mistaken for it the incubation of small-pox. 

The symptoms that follow, as the sick stomach, loss of appetite, slight 
cough, heaviness of the head and eyes, occur now just as they did in the 
time of Sydenham. The only irregularity in Sydenham's description 
consists in the large red wheals, which have not, in our cases, made their 
appearance, nor have I often observed them. The swelling of the eyelids 
continues the same. The vomiting occurs particularly in children, and 
not in adults ; we did not notice it in these cases. Looseness of the 
bowels is the next symptom mentioned. This is not now a constant 
symptom in the early stages of measles, but it is to be recollected, that 
the descriptive account of the disease by Sydenham has reference to an 
epidemic which took place in 1670. The diarrhoea I set down as an 
accidental symptom, and, as such, it probably complicated the epidemic 
of that year, just as it does in our time those of other seasons. 

We next pass to his description of the eruption, which he characterizes 
most accurately. We have it now, as then, appearing first in the form of 
red spots, resembling flea-bites, which gradually coalesce into semicircu- 
lar, crescentic, and circular shapes, showing themselves first on the face, 
and spreading thence over the rest of the body. As the eruption in- 
creases, there is a diminution of the other symptoms. The eruption is 
found in the mouth and throat, as well as on the skin. In the case of 
negroes, it is of course detected only in the eyes and throat. In the pha- 
rynx and palate, as elsewhere, the eruption is not so much elevated above 
the epithelium, as it is above the surface of the skin. The next part of 
the description is doubtful — that is, the mode of disappearance of the 
eruption. It does not totally disappear on the eighth or ninth day, as 
alleged by Sydenham, for traces of it remain for some time afterwards, in 
copper-coloured spots, as shown in the cases in our wards; even after the 
spots entirely disappear the skin remains rough and dry. I do not at this 
time intend to go more largely into the ordinary symptoms of measles, for 
I can scarcely add any thing to the graphic description which I have read 
to you from Sydenham. While at Paris, and at the Hopital des Enfans 
Malades, I collected a mass of observations on this subject ; but not yet 
having been able to analyze them, I must defer presenting them to you to 
some future time. I shall now call your attention to two of the accidental 
symptoms which may complicate the regular course of measles, and often 
become the sources of great danger. 

The first is bronchitis of a severe character. A slight bronchitis may 
be looked upon as a necessary symptom of the disease ; it is to be deemed 
accidental when it appears under an aggravated type, or when the inflam- 
mation runs into the parenchyma of the lungs, and takes on the form of 
lobular pneumonia, which is similar to the pneumonia following the bron- 



MEASLES — COMPLICATIOxNS. 637 

chitis of young children. This accidental symptom occurred in the man 
Morris, whom you recollect in the first ward, about the eighth or ninth 
day, when the eruption was fading, and our attention was directed to the 
development of moist rhonchi on the right side of the chest, showing the 
xistence of severe bronchitis, with considerable dulness on the middle 
nd posterior part, and some on the anterior region of the left side — a 
common seat of lobular pneumonia in measles. Instead of getting well, 
the man has remained ill, exemplifying the general rule, that, when lobu- 
lar pneumonia is developed, after the subsidence of the eruption, it lasts 
for a considerable length of time. The signs by which its appearance is 
to be detected, are dulness on percussion, with a sub-crepitant rhonchus, 
and a slightly bronchial respiration. In place of attacking the mass of 
:he lung, and rendering it solid, the inflammation appears in the isolated 
lobules, leaving among them portions of the lung still permeable to the 
air, which prevent the development of loud bronchial respiration. The 
respiration, in the very early stages of the disorder, and in the portion of 
the lungs which is not inflamed, is not lost, but rendered louder, and 
roughened. 

In the case of the boy Perry, the pneumonia appeared on the eleventh 
day of the disease, after the eruption had entirely subsided, no traces of 
being left but a few copper-coloured spots. His right lung was attacked, 
as is commonly the case ; perhaps, from its greater size, and from the cir- 
cumstances of the patient's lying upon the right side. The lower, and 
not the middle and upper lobes, was attacked ; in this respect as well as 
in others, it is like ordinary pneumonia, but differs from it in the loudness 
and looseness of the crepitus, which ceases in regular inflammatory pneu- 
monia as soon as the entire substance of the lungs becomes solidified. In 
the boy's case, as in that of Morris, convalescence has been very slowly 
established, and is yet by no means perfect ; he is still lingering in a 
somewhat critical condition. In the case of Morris, I entertained, for a 
time, some fear of the existence of tubercles, the development of which is 
thought to follow attacks of measles : I say, is thought, for I am by no 
means certain that there is any necessary connection between the two 
affections. 

The treatment proper to meet this complication of measles is neces- 
sarily various. At the Hopital des Enfans Malades, during my residence, 
local depletion by cups and leeches was largely employed by Dr. Guersent. 
But the debility, consequent on this mode of treatment, was favourable to 
the reproduction of the disease in other parts of the lungs, especially as the 
pneumonia was observed almost invariably in children of feeble constitu- 
tion. The proper rule for the employment of bleeding leeches, is to 
confine them to cases in which there is excessive dyspnoea, and a rapid 
extension of the pneumonia is going on. It extends through the lung 
most rapidly, in stout, robust children, and in them leeching does good. 
In the ordinary lobular pneumonia, as well as in that which follows 
measles, after one or two cuppings, the best treatment consists in small 
doses of ipecacuanha. By persevering with this remedy, until the expec- 
toration, or rather the secretion (for with children there is no expectora- 
tion, as they swallow the discharge), is freer, the patient is relieved, and 
we may then complete the cure, by the exhibition of tonics and a generous 
diet. Above all, attention is to be directed to position. If the child lie 
constantly on its back, the development of pneumonia is almost certain. 



638 GERHARD'S CLINICAL LECTURES. 

It must, therefore, be moved frequently from one side to the other, and 
be from time to time raised in bed or carried about. In addition to 
ipecacuanha in expectorant doses, the sulphate of quinine and some pre- 
paration of iron, in small quantities, may be given, combined with a 
generous diet, if the child should become feeble, and the quantity of red 
blood should diminish. You will find, that in my lectures, gentlemen, I 
am not at all disposed to insist on too rigid a diet. I have seen so much 
mischief result from the continued enforcement of a rigid diet, in accord- 
ance with the mode of practice which was prevalent in France a few 
years ago, that it is with great caution, and no little reluctance, that I ven- 
ture upon it, except for a short period. In some of the wards of the Enfans 
Malades, the practice was to place the children on a rigid diet, and the 
results were certainly far from favourable. 

In the cases under notice, by pursuing the practice indicated, we have, 
in a great measure, succeeded in getting rid of the accidental symptoms. 
But there is still some cough, and other traces of lingering bronchitis. 
What is now the proper treatment ? It should be principally hygienic. 
The patients are to go freely into the open air, taking internally, at the 
same time, some of the milder tonics. 

The next accidental symptom, likely to complicate the course of measles, 
is severe diarrhoea, near to the close or after the terminatiori of the disease. 
At. the Enfans Malades, the children died in two ways when measles 
proved fatal, — of lobular pneumonia, during the active period of the 
affection, and of diarrhoea, at the end of it. The lobular pneumonia 
usually showed itself about the sixth day, the bronchitis appearing much 
earlier ; but the diarrhoea does not usually come on until the eruption is 
almost over and desquamation was taking place. If this diarrhoea be but 
slight, no danger need be apprehended from it, and we rather avoid much 
interference with it. Indeed, it is generally looked upon as a safeguard 
to the child, and is, therefore, suffered to run on. But I do not consider 
the diarrhoea as slight and not to be checked, if it exceed four, five, or 
six stools during the day, and continue until it is accompanied by emacia- 
tion of the child, with paleness and dryness of skin. This variety of con- 
secutive diarrhoea depends commonly upon a particular state of the mucous 
membranes, in which they are pale and soft, seeming to be acted on by 
the altered fluids in the body, and instead of being themselves the seat of 
very active disease. I showed you the other day, at an autopsy, a similar 
state of the mucous membrane, but occurring in the stomach ; in this case, 
however, it was probably produced by the action of the fluids after death. 
This state of the mucous membranes, as it occurs in measles, I do not 
regard as an effect of inflammation, nor is it to be treated as such. 
Depletion, of any sort, here does no good, nor do remedies specially 
directed to the bowels always prove of much service. You must act on 
the skin until its functions are restored, and for this purpose nothing is 
better than the sulphur bath, made by dissolving the sulphuret of potassa 
in water. I have seen children recover, at the Enfans Malades, under 
this treatment with astonishing rapidity. It not only relieves the particular 
symptom to which it is addressed, but much improves the general con- 
dition of the patient. Indeed, it was remarked by Jadelot, that the same 
remedy, employed for the management of itch, not only cured that affec- 
tion, but besides left the patient in a general state of health and embon- 
point. If the sulphur bath cannot be administered, one of warm salt 



MEASLES — DIARRHCEA. 639 

^ater may be substituted. In addition to this treatment, adapted to the 
kin, slight opiates may be resorted to, with small doses of ipecacuanha, 
ind astringents, which are supposed by some to act chemically upon the 
jowels. But depletion, by leeches or cups, must be abstained from, and 
he diet should be nutritious, but of a nature to leave little residue for 
he colon. 

The last variety of accidental lesion which occurs during measles is 
acute diarrhoea during the height of the affection. This complication I 
have not witnessed during the epidemic at the hospital, though it was a 
very frequent occurrence at the Enfans Malades, in 1832, which was just 
before the cessation of the Asiatic cholera at Paris. That epidemic of 
measles was probably similar in its character to one described by Syden- 
1am. The disorder is dependent on acute inflammation of the colon, and 
shows itself at the most intense period of the eruption ; it is attended, 
generally, with the usual symptoms of dysentery, considerable pain, stools 
small in quantity, containing slime, sometimes patches of false membrane, 
and blood ; in fact, we have a regular attack of acute dysentery, compli- 
cating the measles. The complication is, I believe, most apt to occur in 
the summer months of the year. That is, measles are subject to the 
general rule of pathology, which determines the nature of the accidental 
symptoms attending self-limited diseases. Thus, in the typhus fever 
which was epidemic here during 1836 and part of 1837, we had, during 
the winter, symptoms of the acute affection most usual in winter, as those 
of the chest, and, in summer, it was complicated with diseases which are 
endemic in hot weather, as dysentery and disorders of the alimentary 
canal. Neither of these accidental affections was in any manner a neces- 
sary accompaniment to the typhus. The complications of measles follow 
the same rule, except that both the inflammations of the lungs and the 
bowels are more frequent than in typhus fever ; we have, in other words, 
very generally lobular pneumonia occurring in the measles of winter and 
early spring, and affections of the alimentary canal when the epidemic 
takes place in the summer months, particularly July and August. 

The post-mortem appearances, in this affection, differ from those of 
ordinary diarrhoea. If closely examined, the colon and rectum are found 
to be covered with patches of lymph, and their mucous membrane is 
much disorganised, and of a violet tint, as in severe dysentery. So uni- 
versal were these appearances on dissection, during the epidemic at the 
Enfans Malades, to which I have just alluded, that a gentleman, who 
was observing it, thought" that he had discovered a new law of pathology, 
and that there was a constant connection between rubeola and inflamma- 
tion of the colon. He was, however, mistaken, and from his error we 
may see the importance of observing with care the phenomena of several 
epidemics, and of again and again repeating these observations, before we 
allow ourselves to make from them any general deductions. 

The treatment at the Enfans Malades for the dysenteric symptoms was 
the same that is employed in ordinary dysentery. It was attended with 
no great success, but it must be remembered that severe dysentery is at 
all times a difficult affection to treat. The remedies, however, should 
certainly be the same when dysentery forms the complication of which we 
have been speaking as in the common variety where it is the primary dis- 
order. In the early stage we must have recourse to antiphlogistics, used 
with some freedom, by leeches and cups to the region of the colon and 



640 GERHARD'S CLINICAL LECTURES. 

the anus. The dysentery differs essentially, as I have before said, from 
the diarrhoea occurring at the close of measles, and we have no fears here 
about the propriety of an energetic antiphlogistic treatment ; it affords 
prompt and great relief. We may afterwards administer opiates in very 
small quantities, and moderate doses of ipecacuanha. Calomel is so 
rarely employed in France, that I never saw it prescribed in those cases, 
and have not been able to test its efficacy in this affection frequently 
enough to speak of the advantages of using it. The after-management of 
the dysentery of measles is also much the same as of common dysentery, 
except that the former will be found to be of greater obstinacy than the 
latter usually is. 

From these details, then, we deduce the following corollary. In mea- 
sles, as in other diseases of known duration, we have one constant set of 
symptoms, as the eruption, and febrile movement with anorexia, thirst, 
restlessness, &c. ; and next, a series of accidental symptoms, which ex- 
tend from the slight bronchitis, necessary to the affection, to severe bron- 
chitis and lobular pneumonia, and from the slight attendant diarrhoea, to 
diarrhoea of the subacute form, and severe inflammatory dysentery. It is 
to these accidental symptoms that you are to pay particular attention ; and 
by doing so, I am persuaded you will much diminish the mortality of 
measles, which depends, as in typhus fever and small-pox, N mainly on the 
severity of the accidental complications. 

There remain to be noticed some varieties of measles, not observed 
here in the late epidemic. The first variety occurs in the other exanthe- 
mata, and consists in an imperfect development of the eruption. This is 
not so frequent in measles as in scarlatina ; but we have occasionally 
coryza, a flow of water from the eyes, and cough, with but a very slight 
eruption, or one that is confined to the face. This is still a genuine, al- 
though an anomalous form of measles. 

The second variety consists in the severe complication of internal in- 
flammation with the eruption, which disappears soon after the beginning 
of the disease, and may be looked upon as suppressed. You then have 
universal bronchitis, the whole mucous membrane being affected with in- 
flammation of an intense character, instead of the usual slight blush. We 
have then a grave internal affection, occasioned by the want of action 
on the surface of the body, the disease being, as it were, concentrated in 
the internal organs. This variety is always attended with great danger. 
It is to be treated by active counter-irritation of the skin, to supply the 
place of the absent eruption ; for this purpose, sinapisms, the warm bath, 
and the like remedies are to be resorted to. 

The third variety is the black measles, or rubeola nigra. This is not a 
real variety. It occurs in feeble children, in whom the blood is in a dis- 
solved state, as from scurvy ; or it may depend on the sudden develop- 
ment of lobular pneumonia, preventing the proper decarbonization of the 
blood in the lungs, and giving it a general dark tint. 

These varieties are almost the only ones that you will meet with in 
practice, and on which it is therefore proper to dwell. Rubeola sine 
catarrho I have never seen — I scarcely believe in its existence. Some 
change in the bronchial mucous membrane is always to be detected ; there 
is a dry rhonchus indicating a thickening of it, or we have at least some 
traces of a moist secretion. Cough is not a necessary attendant upon a 
slight bronchitis, and it is impossible to decide with certainty upon its 



SEROUS MEMBRANES. 641 

ion-existence without a very careful examination, and I suspect it is th 
bsence of close observation that has given rise to the variety of rubeola 
sine catarrho. 

I have presented to you to-day but few clinical illustrations, as I was 
lesirous of giving you a somewhat detailed descriptive notice of measles, 
i disease of frequent occurrence, and which now prevails epidemically. 
I have insisted particularly upon the importance of the accidental symp- 
oms which are most frequent, for although other organs, as the brain and 
the windpipe, are sometimes the seat of grave lesions, they are not usually 
so much affected as the thoracic and abdominal viscera. There is an- 
other complication which is not rare in some epidemics, that is, the gan- 
grenous sore mouth of children, of which I shall treat at a future time. 

Measles is perhaps a more frequent cause of after ill health than any of 
the other exanthemata. The bad effects of small-pox and scarlatina are 
usually confined to the course of the disease ; they destroy life at tin- 
period or soon after. But measles, though less dangerous during the 
eruption, may leave behind it greater organic lesions than either of the 
others. The effects of lobular pneumonia and diarrhoea are not easily ^ot 
rid of; and, after a supposed convalescence from measles, we but too 
often see our little patients wasting away from emaciation, and after a 
lapse of a few months, perishing from the consequence of one or other of 
these dangerous complications, or from tubercles in the lungs, the lym- 
phatic glands, or the follicles of the intestines. 



LECTURE III. 

Inflammations of serous membranes — Pathological anatomy — General symptoms — Pleurisy — 

Tuberculous peritonitis, <Scc. 

In my lectures on pathological anatomy I have already pointed out to you 
the distinctive characters of the inflammations of the serous membranes. 
As you, no doubt, remember, these characters consist in the bright arte- 
rial injection of the membrane, and the secretion into its cavity of lymph. 
serum and pus. The lymph is secreted very early ; I once detected it in 
a case of pneumothorax which proved fatal in an hour after the perfora- 
tion : at first it is secreted in the form of minute points scattered thickly 
over the inflamed surface ; as these points become more numerous, they 
gradually run together, until the whole surface is covered by a tolerably 
uniform coating of lymph, which is then called a false membrane. Por- 
tions of the lymph are afterwards detected in flakes interspersed through 
the serum. The liquid consists chiefly of serum, which is slightly turbid 
from the admixture of lymph, and of a small portion of pus, which gives 
it a yellowish tinge. The pus is not abundant in acute inflammations, 
and in subjects of a feeble constitution is scarcely perceptible ; but when 
the inflammation becomes chronic the proportion of pus gradually becomes 
more considerable, until it at last forms the whole of the liquid. It is 
then called an empyema when formed in the pleura. 

The manner in which the gradual absorption of the liquid occurs, and 
the two surfaces of lymph become organised, and finally adhere together, 
42 



642 GERHARD'S CLINICAL LECTURES. 

must also have become so familiar to you as to require no further descrip- 
tion at present. 

Serous inflammations may be either primary or secondary. When 
secondary, they are usually dependent, first, on the previous existence of 
inflammatory rheumatism, secondly, on disease of the organs which they 
invest, and thirdly, on the existence of a tuberculous diathesis. I shall 
not now dwell upon the rheumatic causes of serous inflammation, as I 
entered into this subject, at a former lecture, when speaking of a case of 
acute articular rheumatism in which pericarditis occurred. Its connec- 
tion, too, with disease of the parenchymatous tissues covered by serous 
membranes, we shall discuss at length, on some future occasion, when 
we may see that inflammation of the lungs, liver, that, in fact, every lesion 
of an organ, gives rise to more or less inflammation of its serous covering. 
This process is an effort of nature to isolate and protect the diseased 
organ. The third cause of serous inflammation, that is, the existence of 
a tubercular diathesis, is the most complicated, and presents the most 
numerous points for examination : int» some of these we shall enter in 
the present lecture. The connection between serous inflammation and 
tubercles is the more important, from its enabling us to recognise a num- 
ber of tubercular cases, otherwise obscure, by reasoning upon the law of 
pathology, that tubercles are so often connected with inflammation of these 
membranes. 

In addition to those above mentioned, there may be other causes of 
secondary serous inflammation ; they may be mechanical, as perforations, 
outward violence by blows, and the like, and the influence of cold which 
may be felt in the membrane surrounding the joints, intestines, lungs and 
heart, producing a primary inflammation. 

That secondary serous inflammations are not of much more frequent 
occurrence than they are, is to me a matter of surprise, when I reflect 
upon the close connection of the organs with their serous investment ; at 
all events, they are comparatively of more importance than the primary 
forms, from their greater fatality. 

There are certain signs common to serous and other inflammations, by 
which they are generally ushered in. These are chill, fever, and sweating, 
with a general malaise, or feeling of wretchedness, loss of appetite, thirst, 
and in fact the ordinary febrile symptoms. They may, however, be 
entirely absent, and I have seen patients die of acute peritonitis without 
either fever, thirst, or severe pain. The pain accompanying serous inflam- 
mation is usually sufficiently indicative of its character. It may be said 
to be specific, being lancinating, sharp, acute, resembling such as would 
be inflicted by the stab of a knife. It is ordinarily described by patients 
in these terms ; it may, however, be so slight as not to confine the patient 
to bed, in fact, not severe enough to enable him to localize the disease. 
Patients often come into the ward, with the general febrile symptoms 
above mentioned, without local suffering enough to allow them to fix the 
particular seat of their disease. It is obvious, then, that we cannot trust 
to the character of pain, in determining the nature of the affection, but 
must resort to physical examination, the phenomena of which, resulting 
from the identity of the liquid secreted, will be always the same. 

There is, besides, a disordered action of the organ invested by the 
serous membrane ; in pericarditis, of the heart, in pleurisy, of the lungs, 
and in peritonitis, although not so distinctly marked as in other inflam- 



8ER0US MEMBRANES. 643 

mations, there is generally sufficient evidence of disturbance in the action 
of the bowels. 

The state of the pulse is another sign, supposed to be especially cha- 
racteristic of this disease. But you recollect that, in the case of the man 
Robb, the pulse was merely moderately frequent, seventy-six per minute, 
notwithstanding the pericardium was inflamed ; and, in another patient, 
labouring also under intense serous inflammation, you noticed also that 
it was very nearly of the same frequency, that is, decidedly not febrile. 
The character of the pulse is, therefore, a faithless sign of the existence of 
serous inflammation ; it may be peculiar, small, wiry, and of intense 
activity, in which case bleeding is demanded without delay ; but these 
distinctive features are not always present. 

In the patient noticed to-day, the pleurisy was nearly, though not 
entirely, latent. The woman, whose case was before you, had neither pain 
nor fever, although there was an effusion into the pleura of a quart and 
more in amount. The signs of this effusion were merely physical. This 
latent pleurisy is a common affection with old people, many of whom 
perish from it, when supposed to die simply from the decay of old age. 
In young persons these diseases are not so often latent, except in a very 
chronic form, or where the patient has been exhausted by previous illness. 
An example of this was furnished by the case that terminated yesterday 
fatally at the hospital. It occurred in a patient who had been labouring 
under chronic peritonitis for a year previously, and who was taken about 
a week since with a slight increase of his ordinary pain, accompanied by 
severe prostration, which carried him off in a few days. An exception 
to this rule, however, occurred at the Pennsylvania Hospital three years 
since in the case of a man who was run over upon the belly by a cart. 
He suffered but little pain, from the first day, and was afterwards suddenly- 
carried off, although the only alarming symptom was extreme exhaus- 
tion. Very extensive peritonitis existed, but without pain, although the 
intestines were covered with lymph. You see, therefore, how difficult it 
is to recognise the presence of serous inflammations, from the functional 
signs which are presented. If we had no other means of examination, or 
if we omitted physical exploration, because there were no special symp- 
toms to arrest and direct our attention, we should be constantly in error. 
For example, it is a very common occurrence with labouring men, suf- 
fering from chronic effusions into the pleurae, to complain of pain, not in 
the region of the pleura, but lower down, in the flanks, whence they are 
sometimes treated merely for lumbago. In such cases, there is absolutely 
no rational symptom to indicate the nature of the disease and the proper 
mode of treatment : it is by the local signs only that the true character of 
the affection can be traced. 

The duration of serous inflammations is by no means fixed. It may be 
divided into two periods, the one including the time that passes during 
the increase of the effusion ; the other that during its stationary and 
declining stage. After effusion has taken place, it is not possible to cure 
the patient abruptly ; time is absolutely required for the consolidation of 
the false membrane, and for the absorption of the pus and serum that 
have been secreted. In all acute inflammations of serous membranes, if 
you see the case only after effusion has taken place, you may safely predict 
that your patient will not be well, at least, for several days; and the 
rapidity of the recovery will depend upon the quantity of liquid which 



644 GERHARD'S CLINICAL LECTURES. 

has been effused, and the time it has remained in the pleura. But, if you 
are called to a case, say of pleurisy, at the beginning of the attack, while 
there is merely slight inflammation without much effusion, the patient 
may get well abruptly, and the morbid secretion may be limited to a 
little lymph, which is a necessary consequence of all serous inflam- 
mations. 

I do not intend now to enter at length into the peculiarities of treatment, 
nor into a detail of the physical signs, belonging to the varieties of serous 
inflammations, except so far as they may be exemplified by the cases 
which I shall bring before your notice. The remarks which I have just 
now made were necessary in order to make clear a number of cases, the 
histories of which I shall presently relate to you. You must bear in mind 
the distinction which I made between primary and secondary serous 
inflammations. The first of these is rarely fatal, except in the brain or 
heart; by interference, you may shorten its course, but you expect it to 
get well under any circumstances. Inflammations of this character depend 
merely on atmospheric vicissitudes or oilier such cause, and are not pre- 
ceded by a tubercular lesion, or connected with this diathesis, nor are 
they the result of a perforation, which is generally irremediable. When 
you have a secondary serous inflammation, you are to look upon it in 
most cases as an effort of nature for the preservation of the part ; and 
when it is complicated with inflammation of the parenchyma of the organ 
which it invests, it is a curative and preservative process, and is not to 
be interfered with, unless it is of that severe character which endangers 
the life of the patient. 

The first illustration, which I shall bring before you to-day, is the ter- 
mination of the case of the man Robb. At the last lecture, I mentioned 
to you that the rheumatism was almost cured. The affection of the heart 
was then, and is still, persisting, although it is now chiefly limited to the 
internal membrane of the heart, and the symptoms are still so severe as 
to prevent the man's yet leaving his bed — a proof of the difficulty of sud- 
denly arresting diseases of this nature. These cases of serous inflamma- 
tion, occurring during an attack of rheumatism, generally assume a cha- 
racter altogether independent of the course of the latter affection : the 
great fire goes out, but the smaller burns slowly on. Not only, indeed, 
does this cardiac inflammation run its course, but it often leaves behind 
it organic changes in the heart, that may last for a succession of years, or 
for life, in the form of thickening of the valves, or adhesion of the laminae 
of the pericardium. Numerous cases of extensive disease of the heart 
take their origin in an attack of rheumatism ; they may, on the other hand, 
be of a slight character, and entail no greater disturbance of the economy 
than slight palpitations, and an inability to use the same amount of active 
exercise as in perfect health.* 

The next case I shall notice is somewhat curious ; it is pleurisy, oc- 
curring in a young Irish- woman, Isabella M'Gargee. Jn December, 1837, 
she was exposed to great fatigue, and suffered much mental anxiety dur- 

* This patient was perfectly cured by rest, some local depletion, and a blister: his cure 
was absolute, for three years after he was engaged in very laborious work without the slightest 
disagreeable feeling about the heart, or any abnormal sound. In most cases I use depletion 
more freely, but from the general aspect of this case I was induced to resort to bleeding of any 
kind in a very moderate degree, and the result was extremely favourable. It should be remem- 
bered that there was little pain and no febrile excitement. These afforded the chief reasons 
for abstaining from much active treatment. 



PLEURISY. 645 

ing the illness of a relative ; she was then taken ill with severe pain in 
the region of the heart, dyspnoea and palpitation ; for these symptoms she 
was bled and blistered with relief. Her health, however, was not entirely 
restored ; there was still palpitation, at times cough and some oppression. 
At the beginning of April, she worked very hard in a damp cellar, wash- 
ing clothes, and was seized, in a day or two afterwards, with fever and 
pain in the right side, extending from the breast towards the nipple, and 
much increased by respiration, or by the cough, which was short and dry, 
not frequent. There was also pain caused by lying on the affected side, 
with considerable oppression. The gradual increase of these symptoms 
obliged the patient to enter the hospital. There was no edema of the 
limbs, and but moderate palpitation ; there was no important previous 
treatment, and the patient was not strictly confined to her bed. 

We now inquire if the disease can here be recognised at the first glance, 
from the detail of symptoms gathered from the patient. It cannot. Let 
us enter into an examination of the symptoms. In the first place, can the 
affection be neuralgia? It has some points of resemblance with this dis- 
ease, but it differs from it in many particulars which are sufficiently well 
marked. First, it is not common for any considerable degree of cough 
to exist in neuralgia, nor have we in it a steady, local pain, as in the case 
described. Another set of symptoms, which establishes the difference 
between the two affections, is that belonging to the countenance, the 
medical physiognomy of the case. This is characteristic, not of neural- 
gia, but of an intense pectoral disturbance. 

Satisfying ourselves that it is not neuralgia, we make a general diag- 
nosis of an acute disease of the chest, first, from the severity of the dys- 
pnoea present, established by the spasmodic contraction of the chest and 
of the nostrils ; and, secondly, by the alteration in the colour of the coun- 
tenance, in the dark blue tinge of the lips and flush of the cheeks. This 
is not purple enough for the existence of pneumonia, and we, therefore, 
infer, that our case is, probably, one of bronchitis, pleurisy, or acute 
phthisis. 

Having carried our examination thus far, let us proceed to discriminate 
between the affections, to which we have reduced the case. This can be 
done only by physical exploration, without which it is impossible to re- 
cognise with absolute certainty the distinctive features of the disease. 
What, then, are the physical signs which establish the character of the 
affection before us? First, we have an abnormal development of one 
side of the chest, at the lower part, and diminishing gradually in ascend- 
ing. This, at once, settles satisfactorily the nature of the affection ; it is 
a pleurisy. Had the development been confined to the anterior part of 
the chest, it might have been emphysema, or, had it been local, pericar- 
ditis ; but only a pleuritic effusion could have made it what it was. Next, 
we have immobility of the ribs : in the present case this could result only 
from pain, from distension, or from old adhesions, 'lhe history of the 
case disproves the probability of the existence of old adhesions on the 
right side ; so that from the pain, then, we again deduce the presence of 
acute pleurisy. 

Continuing the examination, we next proceed to percussion, which 
yielded the following results. There was flatness in the lower posterior 
half of the side of the thorax, and of the lower third on the anterior part ; 
as well as of the lower half of the axilla. Thus far, we can diagnosticate, 



646 GERHARD'S CLINICAL LECTURES. 

with certainty, the existence of pleurisy ; the flatness followed the line of 
gravity, or, in other words, corresponded with the situation of the liquid, 
which, following the ordinary laws of liquids, accumulated in the bottom 
of the chest, just as if it had been contained in a common bag. 

We continued the examination by auscultation. Had the disease been 
pneumonia, we should have had bronchial respiration and a dry crepitus. 
This was not the case, as the lung was quite permeable to the air, and 
not a hard, solid mass. There was no rhonchus, for there was no liquid 
in the bronchial tubes. The physical signs, then, have led us to a cer- 
tain conclusion as to the nature of the affection. In many cases of pleu- 
risy, when the lung is more condensed, we have, however, a bronchial 
respiration, but no crepitus, unless complicated with pneumonia. 

The next question that presents itself is, as to the primary or consecu- 
tive character of the disease. To solve this question we entered upon an 
examination by auscultation of the other side of the chest ; there was, 
here, no evidence of the existence of tubercles, in any great numbers, 
but, from the fact of there being some dulness on percussion, there was 
reason to suspect their presence, though not to determine it with any cer- 
tainty. Besides, from the circumstance of the mutability of the situation 
of the pain, as there had been, you know, a previous attack on the other 
side of the chest, the existence of tubercles was rendered probable. It is 
a law of pathology, that, if a pleurisy appear on one side of the chest, and 
some time afterwards show itself on the other, it, in all likelihood, is de- 
pendent on the presence of tubercles. This law of the double pleurisy, 
as it is called, was discovered by Dr. Louis, and, in most cases, may be 
relied on with certainty. I infer, then, that, in this case, the pleurisy 
was probably tubercular. 

Besides the suspicion of tubercles as a predisposing cause of pleurisy, 
the patient is labouring under an undoubted disease of the heart. It began 
during the acute inflammation of the early part of the winter, when the 
pericardium was involved at the same time with the pleura. As a con- 
sequence of that inflammation, we have hypertrophy and dilatation of the 
heart. 

The treatment of this patient has been active ; she was bled to sixteen 
ounces, was cupped, and has since taken tartarized antimony and digi- 
talis. Under these remedies, with rest and restricted diet, she is rapidly 
improving. 

The remedy here used, tartar emetic, is found to answer perfectly well 
in the management of pleurisy. It increases the sweating, and promotes 
absorption directly ; the digitalis has a similar action through the medium 
of the kidneys. In pleurisy, when the inflammation is circumscribed, 
local depletion is the best treatment. This acts very promptly in serous 
inflammations, although it has but slight influence over the inflammations 
of parenchymatous structures. In the latter case relief is afforded only 
in proportion to the quantity of blood abstracted, while in pleurisy it is 
in proportion to the nearness of the point of abstraction to the seat of pain. 
The pain is relieved, also, by the application of warmth to the part, by 
poultices and fomentations. These, however, are not to be withdrawn 
suddenly, or without the substitution of a thick pad of carded cotton or 
wadding; otherwise they only do harm, by the alternation of heat and 
cold which takes place. The advantages of these local applications can- 
not be too highly estimated. I often rely more upon them than upon 



TREATMENT OF PLEURISY. 647 

more powerful remedies, which, if they relieve pain, at the same time 
diminish the strength. 

The treatment of ordinary simple pleurisy is not a very complicated 
affair. And I would remark, that every case, in which there is no posi- 
tive evidence of a change in the functions of nutrition, even though there 
may be strong ground of suspicion of a tuberculous or other chronic dis- 
ease, is to be regarded in the treatment as a simple pleurisy. The treat- 
ment of Dr. Louis, which I do not, however, follow in all cases, consists 
in small bleedings, combined with the internal administration of tartar 
emetic, nitre, digitalis, and diuretics. Of sixty cases that I saw him treat, 
he lost not one. It may be inferred, that is an effectual plan of treatment 
for simple pleurisy. I may add, that, in a simple case, if effusion take 
place, you need not be very uneasy, if it is slow to absorb, provided the 
case is otherwise proceeding well. 

Of the remedies, by which chronic pleurisy is to be managed (meaning, 
by chronic pleurisy, cases of more than a month's duration), I shall not 
now treat in full, giving you merely a general summary of them. Blis- 
ters, which, in the early periods of acute pleurisy, are not often necessary, 
and do harm twice for once that they do good, are of signal service in 
chronic pleurisy, scarcely ever doing mischief, and often affecting a rapid 
absorption of the liquid effused. They are to be applied not once, but 
repeatedly. Under their influence, absorption sometimes takes place, 
with astonishing quickness: indeed, it seems, in a few instances, as if the 
fluid was directly poured out from the interior of the chest to the blistered 
surface by a sort of endosmosis. Mercurials, in small doses, are not much 
used by the French, either alone, or in combination with squills and digi- 
talis. But in cases approaching in character to hydrothorax, great ad- 
vantage will be derived from a treatment with calomel, squills, and digi- 
talis, or the simple action of the mercurials alone, either pushed to } tya- 
lism, or nearly so, will be found very powerful, both in the advanced 
stages of the acute and in nearly every period of chronic pleurisy. Even 
an obvious but slight tuberculous complication does not always forbid the 
use of mercury in these cases. In addition to treatment by medicines ; 
travelling, a sea voyage, distractions, a simple change of place, will be 
of much service. The importance of travelling is greatest in those cases 
in which we fear the complication of a tuberculous diathesis. Whether 
there be already formed tubercles in the lung, or merely the constitutional 
tendency to these affections, I am quite sure that by this means and by 
attention to other hygienic circumstances, patients are often preserved 
from a threatened consumption. 

In addition to the case illustrative of one of the most simple serous 
inflammations, I shall say a few words respecting another case, in which 
pleurisy occurred, as a well-marked complication. The case was one of 
pneumonia, consecutive upon tubercles, the existence of which was 
known by unequivocal signs at the upper part of the lung. There was 
something, however, engrafted on the pneumonia. This was pleurisy, 
which was detected by a sign which often occurs in the latter stage of the 
affection, and is then pathognomonic, the bruit de frottement, a sound 
caused by the friction of the surfaces of the pleura, lined with false mem- 
brane, upon each other. It resembles the sound produced by the rub- 
bing of leather or India rubber, and is the same grating sound that was 
heard over the heart of the man Robb, but in the present case it is pro- 



648 GERHARD'S CLINICAL LECTURES. 

duced by respiration, and is synchronous with it. It is, also, fugitive in 
its character, and disappears when the membranes become consolidated. 

I shall conclude with one other case, which terminated fatally a few 
days since, demonstrative of one of the causes of serous inflammations, 
the details and phenomena of which will serve as a key for future inves- 
tigations. It was a case of chronic tubercular peritonitis. My reasons 
for this diagnosis were based upon the conformation of the abdomen, 
which was irregularly distended with gas, upon the existence of lanci- 
nating, griping pains, or alternations of costiveness and looseness of the 
bowels, and upon the pain caused by motion, or the distension consequent 
upon eating ; there was, besides, nausea and vomiting. The peritonitis 
occurred here without any obvious cause, and was, therefore, not primary. 
For there is a law of the economy that chronic peritonitis is nearly always, 
particularly in young persons, dependent on the presence of tubercles. In 
addition to this general law of pathology, the great alteration in the nutri- 
tive functions made the diagnosis of the development of tubercles much 
more certain. It was at first doubtful, from the large distension of the 
abdomen from serum ; but the water here was soon absorbed, and there was 
no recurrence of ascites. There was evidence also of tubercles in the 
lungs, although not very decidedly marked. Had there been no physical 
signs of phthisis the case would have been still positive, but we found a 
sufficient number of signs for the local diagnosis of tubercles. 

Most commonly, tubercles appear in the lungs of adults before they are 
deposited in other parts of the body ; but, in this instance, the applica- 
tion of this general law failed. The patient, some days before his death, 
was seized with sudden prostration, under which he rapidly sank, and 
with some increase of the abdominal pain. 

After death, the following appearances were discovered. There was 
effusion of serum and pus into the abdomen ; in the upper portion there 
was merely serum and lymph, and, in the lower, the intestines were 
agglutinated by false membranes perfectly organised, not vascular, but 
there was red injection in the upper part from a more recent inflamma- 
tion. The cause of this difference was perforation of the intestines from 
tuberculous ulceration of the glands of Peyer, two of which had ulcerated 
through all the coats of the intestine into the peritoneum. The pathology 
of these perforations is the following : — k tubercular follicle in the intes- 
tine enlarges and softens, and is discharged into the calibre of the gut. 
The ulcer left does not heal, and, passing into the chronic state, advances 
towards the serous covering of the intestine, which is sometimes destroyed. 
The peritoneal inflammation is only an attempt of nature to preserve life 
by preventing the discharge of fecal matter into the peritoneum. It fails, 
because the mischief done is too considerable to admit of reparation. 

In the lungs, the only evidence of the presence of tubercles were half a 
dozen grey granulations, that could be felt, but scarcely seen ; while, in 
the peritoneum as well as in the intestines, they existed to such an extent 
as to cause disorganization. This disease is unusually rife among ne- 
groes ; indeed, it is sometimes called consumption of the negroes, in the 
southern parts of our country. It rarely attacks adult males, more com- 
monly females, and is very prevalent with children, in whom it forms one 
of the diseases known as tabes mesenterica, although the mesenteric 
glands are not invariably affected. 

To recapitulate my remarks of to-day : — Serous inflammations may ap- 



ACUTE INFLAMMATIONS OF THE HEART. 649 

pear as primary and secondary. When primary, they are not dangerous, 
except in the brain ; but they are so when secondary, because compli- 
cated with some previous lesion, and occurring in exhausted subjects. 
They are to be treated, in both instances, on pretty much the same prin- 
ciples, by depletion, and acting on the skin with alteratives in the more 
chronic stages. If excessive pain exist, narcotics may be used to relieve 
it, with the topical applications you may see every day employed at the 
hospital. 

For the proper study of tubercular diseases, gentlemen, a knowledge of 
the pathology of serous membranes is indispensable. Previous, then, to 
entering upon the examination of the former affections, I have introduced 
the subject of serous inflammations to facilitate our future investigations. 
The study of tubercular diseases is not, as you have also seen, to be con- 
fined to the chest, but to be extended to all the organs of the body, as you 
will more fully learn at a later period. 

The tuberculous affection of the abdomen, which has been under con- 
sideration to-day, though not the most common form of the disease in our 
latitudes, is one of the most prevalent in southern climates, and is on that 
account the more interesting to many of you. 



LECTURE IV. 

Acute inflammations of the membranes of the heart — Pericarditis — Endoc3rditis.* 

During the past summer I have very frequently alluded to the inflamma- 
tions of the membranes of the heart. It has so happened that we have 
had a very unusual number of these diseases ; you have seen more cases 
of the kind within the past six months than I have observed within the 
last two or three years, and it is very improbable that you will again 
witness so many cases of these affections, in the same short space of time. 
The serous inflammations have been almost endemic in our city, and, if 
we except a moderate proportion of bowel affections, they have constituted 
the prevailing diseases of this period. 

It was for this reason that I commenced the course with acute rheuma- 
tism, and then passed on to the consideration of the serous inflammations 
so closely connected with it. Amongst these, the subject of the mem- 
branous inflammations of the heart was accidentally introduced ; but I did 
not then point out to you the numerous interesting questions arising from 
the study of these inflammations, which you will find of difficult diagnosis, 
unless you are thoroughly acquainted with their pathology and with the 
means of physical exploration. Without the aid of the physical signs of 
the disease, the inflammations of the heart cannot be recognised, except 
in a very small proportion of rases. You have had a recent illustration 
of this fact : a patient, whose case I shall presently detail you, has been 
evidently labouring under pericarditis of considerable intensity ; the effu- 
sion of lymph and serum occurred, as it were, under our own eyes, and 
you were able to trace the gradual consolidation of the lymph, when 
adhesions began to form between the two surfaces of the pericardium, yet 
the patient complained of no pain whatever in the chest, and no uneasiness 
* This lecture was given some months after the preceding. 



650 GERHARD'S CLINICAL LECTURES. 

other than that caused by the rheumatic inflammation of the joints which 
preceded the pericarditis. In but two or three cases was the pain suffi- 
ciently considerable to induce us to suspect the occurrence of any affection 
of the heart; one of these cases, attended with pain and the best marked, 
was that of Robb, which I mentioned when speaking of inflammatory 
rheumatism. He suffered some pain, but it was usually inconsiderable, 
until his entire recovery. The other two were blacks, who were affected 
with inflammation of both membranes of the heart, and recovered, but 
died afterwards of a consecutive dropsy. These latter patients had reco- 
vered entirely of the cardiac affection, and, in all probability, would not 
have fallen victims to the dropsy had they not both laboured under a 
cancerous disease. 

When you examine more fully the history of the cases, you will find 
the other rational signs equally obscure ; I can affirm that the obscurity 
was not owing to a want of appreciation of these signs, for I examined 
the cases in your presence with the most scrupulous accuracy, and you 
can bear witness to the precautions taken to elicit every practicable 
symptom in the case. The inflammations of the heart are, therefore, to a 
great degree, latent, and you must commence their study, with the con- 
viction that their diagnosis is impossible, in a large proportion of cases, 
without a thorough knowledge of their pathology and a sufficient acquaint- 
ance with the physical signs of disease. But if this knowledge be possess- 
ed, and some of you have already attained it, there is no part of medicine 
more perfectly demonstrative in its character, or which is governed by 
more unvarying laws, as to the progress and termination of these diseases. 

I will now relate to you some of these cases, and we can compare 
them together to ascertain how far these remarks are confirmed or invali- 
dated by your own observation. At all events you have been eye-witnesses 
of the facts which I detail to you, and the circumstances of the cases will, 
therefore, be more completely impressed upon your mind, and will carry 
with them a force of conviction and a clearness of detail, which could 
never result from a purely didactic lecture. 

The first case I shall give you is that of a patient, now convalescing in 
our wards from pericarditis, nearly uncomplicated with inflammation of 
the internal membrane of the heart. It occurred, as is most commonly the 
case, during an attack of acute inflammatory rheumatism, and had just 
appeared when the patient came under your observation. The following 
symptoms were dictated in your presence:— 

" David Dargan, aged thirty-eight, a lime-burner, accustomed to drink 
freely, entered my ward September the 2d. On the 28ih of August, after 
drinking rather more freely than usual, he was taken with convulsions 
and became slightly deranged ; he was bled, returned for a short time to 
consciousness, and again became incapable of recollection. On the 29th 
he was stupid and could answer no questions ; the stupor was unaccom- 
panied by distortion or active delirium. No muttering; no return of 
convulsions. Digestive functions good. He was cupped freely to the 
nucha twice ; pediluvia were applied ; he took nitre and the effervescing 
mixture, and was purged. In two days he recovered his intellect, but 
not entirely his memory. Consciousness not quite perfect until the 2d. On 
his return to consciousness, he had pains in both legs, hands, and shoulders, 
with swelling. From the 1st to the 2d there was increase of pain and beat, 
and on the 2d, there was redness. No edema or palpitations. There was 



PERICARDITIS AND ENDOCARDITIS. 651 

intense cephalalgia, which was relieved by cupping. For the last three or 
four years he had flutteringof the heart after exercise, and was short-breathed 
at the same time. This began after an illness of seven months' duration, 
the result of intermittent fever. He had rheumatism ten years ago, after 
being exposed to rain, and two or three times before, but merely local in 
the shoulders, not confining him to bed. He recollected no other illness, 
never had syphilis. At the beginning of the pains, on the 28th, had a 
severe chill, but none after. 

" His condition, on the 2d, was as follows : swelling, heat, and pain in 
the ankles and feet ; slight swelling of the knees ; and redness and swel- 
ling of the hands in nearly all the joints. Some pain, but no swelling, in 
both shoulders, but none in the elbows. Pulse ninety, full, nearly regular. 
Tongue moist and natural. Appetite good; no nausea; stools regular. 
Skin generally warm, scarcely moist. Both sounds of the heart heard in 
the whole precordial region, varying, but never perfectly natural. The 
first sound more or less roughened, the second heard distinctly, rather 
sharp : between the two, or rather at the commencement of the second, 
was heard a very evident bruit de frottement, which could be detected 
over the whole precordial region, but was most distinct over the left 
margin of the sternum, more marked in the erect than in the recumbent 
posture. Impulse of the heart increased and irregular. Percussion dull 
from the right margin of the sternum to the nipple, and from the fourth 
rib downwards. No pain, no dyspnoea, almost no cough, no uneasiness 
on percussion. Spinal tenderness from the seventh dorsal vertebra to the 
fifth cervical, more severe on the spine than on the adjoining parts. 
Cups were ordered to the whole length of the spine, with a sixth of a 
grain of tartar emetic and opium each, every two hours, and low diet. 

" On the 3d, there was great alleviation of the rheumatic symptoms. 
No cough or pain across the chest ; no palpitation. Creaking sound in 
the precordial region more distinct than on the 2d, extending over the 
whole region, and synchronous with the diastole, varying in intensity and 
tone. Impulse of the heart diminished, more diffused. Sounds much 
less loud, and both heard distinctly, the first less rough than on the 2d. 
Prominence rather greater. Percussion dull to an inch and a half beyond 
the nipple, thence to right margin of the sternum. Respiration posteriorly, 
vesicular throughout the chest, resonance of the voice doubtful ; opium 
and tartar emetic continued, twice the quantity of the former, with cups 
to the precordia. 

" On the 4th the pain and swelling were rather less, but there was 
great weakness, which may have been owing to the tartar emetic. Other 
symptoms better. Eight ounces of blood had been taken from the chest, 
by the cups. Percussion now quite clear within the nipple, dulness 
extending nearly an inch and a quarter from mid-sternum. Sounds of 
the heart much louder, the first offering only a moderate bruit de soufflet ; 
the second, near the point of the sternum almost replaced by a simple 
creaking sound, which prolonged itself also into the first, but less dis- 
tinctly ; heard all over the heart, less towards its left margin, very loud 
along its whole sternal region, at times giving a musical tone. When 
the patient was erect, the impulse of the heart was stronger, and the 
creaking more frequent, in fact converted into an incessant grating. 
Eight ounces of blood were again taken from the precordia by cups, and 
the opium and tartar emetic continued. 



652 GERHARD'S CLINICAL LECTURES. 

" On the 5th, the pain was less severe in the hands, more so in the 
shoulders and muscular parts of the arms ; soreness in the muscles of the 
thighs, Jess in the feet ; increase of swelling and puffiness in the knees, 
but not of pain and swelling. No spinal tenderness, cough, or oppres- 
sion ; sleep disturbed by pain ; prominence greater than yesterday ; per- 
cussion clear, however, except for an inch and a half at the point of the 
sternum ; impulse of the heart greater, clearer, sharper ; first sound dimi- 
nished, grating much less distinct, heard chiefly at the point of the 
sternum. On sitting up, the action of the heart was stronger, the grating 
much more distinct, heard under the same circumstances as before ; three 
stools since last evening ; when he took half a grain of ipecacuanha and 
five grains of Dover's powder, twice. To-day, five grains of Dover's 
powder, four times a-day, and cups to the spine. 

" On the 6th, no swelling in the knees, almost no soreness, less of both 
in the feet, none in the left hand, almost none in the right ; soreness and 
swelling in the shoulders not diminished ; no soreness of the back or 
breast. Pulse ninety-two, regular, and softer. Sweating profuse, no 
chilliness. First sound of the heart very short and faint. Second, loud, 
masked by the creaking sound. Percussion duller, to an inch within the 
nipple ; impulse rather stronger. Cups between the shoulders, and 
Dover's powder continued. 

" On the 7th, countenance gay ; shoulders better ; no swelling of the 
hands, almost no stiffness ; knees natural ; very slight swelling in the 
ankles, with a little pain in the right. No spinal tenderness. (Has been 
cupped four times ; twice to prsecordia, eight ounces, each time ; twice 
to spine, six ounces ; twice cupped, before his entrance, to the nucha, 
seven ounces ; and had been bled from the arm.) Pulse quick, regular, 
ninety-five. No prominence in the praecordia. Percussion perfectly clear. 
Dulness very incomplete everywhere. Impulse of the heart more clear ; 
first sound prolonged ; creaking in the second limited to the point of the 
sternum, disappearing when he rises. Sweating profuse, constant. Urine 
rather increased. No chills. Dover's powder continued ; hop poultice 
to the feet. 

" On the 8th, soreness almost ceased in the feet, a little effusion in the 
knees, but no increase of pain ; slight soreness in the points of both 
shoulders. Pulse one hundred and eight, thrilling, regular. Sweating 
continues. Impulse of the heart much stronger, first sound nearly natural, 
a little prolonged ; bruit du cuir so faint at the beginning of the second 
that it would have seemed doubtful, if not previously heard. Treatment 
continued with cups between the shoulders. 

" On the 9th, has pain only in the knees and hips ; less in the shoul- 
ders since the cupping. Sweating, still continues. Pulse one hundred 
and tw r o, quick, thrilling, and resisting. Appetite good ; no nausea ; 
three or four stools daily. Respiration now heard over the whole praacor- 
dial region ; impulse stronger, creaking quite decided in the second 
sound ; first still blowing, less than last evening, when the pulse rose ten 
to fifteen beats. Dry cups were applied to knees last evening with relief 
to the pain. Treatment continued. 

" On the 11th, no pain in the hands ; some cephalalgia. Pupils a 
little contracted. Some wrinkling of forehead. Expression anxious. 
Pulse one hundred, full, thrilling, softer than yesterday. Slight subsul- 
tus ; talking in sleep, says he is accustomed to it when well ; sweating 



PERICARDITIS AND ENDOCARDITIS. 053 

continues ; five stools in the twenty-four hours ; legs restored to motion, 
almost no swelling ; stiffness of right shoulder and arm, including elbow ; 
slight of left ; feels no uneasiness in the chest ; a little soreness appa- 
rently in the pectoral muscle of both sides; first sound of the heart and 
impulse natural ; creaking scarcely heard (has taken no medicine in the 
last twenty-four hours) ; four ounces of wine in whey, and an assafoetida 
plaster to the epigastrium. 

" 12th. Last evening, about seven o'clock, had more tremour, more 
subsultus, countenance the same ; took four ounces of the assafoeiida- 
mixture, every two hours. Enema of twenty drops of laudanum. Slept 
well during the night, awoke once or twice only. Pulse ninety-six, full, 
soft ; pains not increased. Soreness felt now only in the shoulder-joints. 
Bruit de soufflet harsher than yesterday ; a little rasping, creaking, indis- 
tinct ; second sound very clear. Percussion nearly as before, a little less 
clear; assafoetida-mixture continued ; wine omitted ; full diet. 

M 13th. Muttering during sleep ; pain less ; two stools in twenty-four 
hours. Impulse of the heart louder and clearer ; both sounds louder, 
particularly second, which is still a little blowing, still subsultus ; sweat- 
ing. Pulse ninety-two, feeble, regular ; continue assafoetida. 

" 17th. Still has pain in legs and arms ; drowsiness constant ; no sub- 
sultus ; intellect quite clear. Pulse one hundred, regular, small ; motion 
returned to every joint, but some stiffness in shoulders and knees ; sweat- 
ing abundant. Both sounds of heart heard ; creaking not ceased ; more 
diffuse, less loud. Dulness of percussion not increased. Chamomile tea. 

" 18th. Sitting up; no pain except slight in shoulders and knees; 
sounds of heart natural, except slight creaking in second. Convalescence 
confirmed. 

" 19th. Perfectly free from pain, except when moving ; then suffers 
from soreness of limbs ; skin cool, pleasant ; appetite good ; sounds of 
the heart clear ; creaking barely perceptible. 

" 20th. Continues well ; remains a few days longer to confirm his con- 
valescence." 

When you examine the history and progress of this case, you will see 
upon what facts the diagnosis of pericarditis is based. We must then 
examine other cases which have terminated fatally, in order to test the 
correctness of the laws of diagnosis, which I shall lay down. We have, 
fortunately, lost no patient in the present course, during the continuance 
of the pericarditis ; but we shall be able to obtain the necessary evidence 
from an examination of those cases which terminated fatally of some acci- 
dental disease after the termination of the pericarditis, and we then can 
compare those cases with others that have terminated unfavourably at a 
previous period.* 

The signs of pericarditis in one patient varied according to the stage of 
the disease. During the period of effusion, which had already begun 
when the patient came under our observation, five or six days after the 
commencement of the rheumatism, we had the physical signs of pericar- 
ditis, which are clearly described by Dr. Louis. That is, flatness on per- 
cussion to a much greater extent and to a more considerable degree than 
occurs in a healthy subject, decided prominence of the precordial re- 
gion, which was distended and raised up by the liquid, and dulness of 
the sounds of the heart with feebleness of impulse. Now, these signs 

* Some cases of this kind were then mentioned. 



654 GERHARD'S CLINICAL LECTURES. 

become the more characteristic from their constant variation ; the quantity 
of liquid scarcely remained the same for two consecutive days, and you, 
therefore, found the signs of the disease to increase during the time that 
it augmented, while they diminished very rapidly when the pericarditis 
declined. Had the dulness and the prominence of the precordial region 
been permanent, the case could still have been recognised, but there 
might have remained some room for doubt ; for chronic enlargement of 
the heart, particularly if complicated with effusions of serum into the peri- 
cardium, resembles a case of pericarditis in most of its physical signs. 
The resemblance ceases when you watch the case for several consecutive 
days. 

There was another sign indicative of pericarditis, which also served to 
point out to you the variety and stage of the disease. It was the sound 
produced by the rubbing together of the two surfaces of the pericardium 
covered with lymph. This sound occurs during the systole and diastole 
of the heart, especially the latter ; it was, therefore, most evident during 
the second sound of the heart which occurs during its dilatation. This new 
sound was so loud as, in some measure, to conceal the natural second 
sound of the heart, which was, however, never entirely\destroyed, but 
could always be detected by a practised ear, as it were, combined with 
the new adventitious sound. The second cardiac sound was not lost, be- 
cause it depends on valvular contraction, and the valves of the heart re- 
mained nearly in the normal state ; now, had the disease been complicated 
with much inflammation of the internal membrane, as was the case with 
the man Robb, to which I have previously alluded, the motion of the 
valves would no longer have remained free, and we should have found 
either that the second sound was altogether lost, or much changed from 
its natural character. The cause of the grating sound is nearly the same 
in inflammation of the pericardium and of the pleurae; that is, in both 
cases it arises from the friction of tw T o surfaces of serous membranes more 
or less coated with lymph ; it is not precisely similar in the two cases, 
because the quick action of the heart differs greatly from the slow gra- 
dual movement of the lungs in the act of respiration. The grating sound 
of pericarditis, therefore, is more sharp and quick, but less loud and pro- 
longed than that of pleurisy. It is useless to describe this sound to you, 
for you have heard it for yourselves, which answers better than any de- 
scription ; those who have not heard it, may readily distinguish it by its 
creaking, like the sound produced by rubbing together two pieces of 
moist leather, whence it has been sometimes called the " bruit de cuir," 
or feather sound ; a trivial name, which is by no means so expressive as 
that of rubbing or grating sound. It cannot be recognised by one not 
previously acquainted with the natural sounds of the heart, with which 
the slighter shades of this adventitious sound may be confounded. You 
could distinguish it readily in the present instance by a careful analysis 
of the sounds when you found that the sharp clear tone of the second 
sound was more or less cbscured by this rasping sound extending over 
the whole anterior surface of the heart, especially at its middle portion. 
There is but little difficulty in distinguishing the grating sound of peri- 
carditis from the rasping sound caused by thickening or vegetations upon 
the valves ; the latter is more frequent in the systole, is always heard 
most distinctly at the region of the valves, and is not attended with a 
sensation of grating, which is quite perceptible to the touch in most cases 



PERICARDITIS AND ENDOCARDITIS. 655 

of pericarditis. When there is but little effusion the little grating sound 
is more important as a sign, for there is this very dulness on percussion 
and no prominence. 

As the lymph became consolidated, the grating sound gradually de- 
clined, but it has not yet disappeared, although the patient is now in full 
convalescence. Nor do you generally find that this sound will disappear 
quickly ; for, if the lymph form prominences on the surface of the heart, 
it may remain for several months, at least until it is so far absorbed as no 
longer to present rough projections for the grating of the two surfaces 
together. 

The sounds of the heart, properly so called, were both distinguishable 
throughout the whole of this case ; they were somewhat feeble, had lost 
a little of their natural clearness and seemed distant ; but neither of them 
was either very much changed, or had lost its due proportion. In simple 
pericarditis, you will find that this is usually the case. It is true, that the 
motion of the heart is never quite free, and its sounds do not retain their 
full development, but it is also true that the slight aberration from the 
normal sound which occurs in simple pericarditis, is very different from 
the rasping or very rough bellows-sound heard in cases of endocarditis ; 
whether this latter disease be simple or merely a complication of the peri- 
carditis. You had a beautiful illustration of this distinction when you 
examined the case of the patient Robb, which was described when speak- 
ing of acute articular rheumatism. In him there was both endocarditis 
and pericarditis, and we had the distension and dulness of sound indica- 
tive of pericarditis, with the rough and harsh sound, caused by the thick- 
ening and consequent stiffness of the valves. The chain of proof of what 
I have just advanced is, with me, conclusive ; for I have seen cases of 
both endocarditis and pericarditis quite uncomplicated one with the other, 
and, therefore, well suited for studying the signs of these diseases in their 
simple state. I have again seen other cases in which the symptoms of 
one disease greatly predominated, without being perfectly unmixed one 
with the other. Some of these cases terminated fatally, and the examina- 
tion after death proved the correctness of the diagnosis. The most recent 
cases of heart disease of the kind to which I am now alluding, were fur- 
nished by two patients affected with pneumonia ; both died of the pneu- 
monia, which was aggravated by the disease of the heart, although this 
latter affection was not, in itself, sufficient to cause death ; and we could, 
therefore, test our diagnosis as applied to a membranous inflammation of 
the heart of moderate severity and in itself not fatal. 

The first case occurred in the last winter ; it began with laryngitis, 
attended by extreme prostration ; the patient was then attacked with 
pneumonia, of which he died. During the course of the pneumonia, the 
patient was taken with pericarditis ; there was a manifest dulness in the 
precordial region, a slight prominence, and a distinct, though feeble 
creaking sound, chiefly heard during the dilatation of the heart. The 
sounds of the heart scarcely differed from the normal standard, although 
the impulse was somewhat feeble. As there was some obscurity in the 
case, the patient was, at my request, examined by my colleague, Dr. 
Pennock, who concurred with me in the diagnosis. The patient died, 
some days afterwards, from the pneumonia ; on the autopsy we found 
patches of false membrane scattered over the surface of the pericardium, 
proving the existence of pericarditis. There was no liquid in the peri- 



656 GERHARD'S CLINICAL LECTURES. 

cardium ; this again corresponded with the accuracy of the diagnosis, for, 
previously to the death of the patient, the pericarditis had evidently de- 
clined, and the dulness on percussion had been gradually replaced by the 
natural resonance. This case, which occurred during the course of the 
present winter, afforded conclusive evidence of the actual relation between 
the signs of pericarditis and the corresponding anatomical lesions. 

The second case presented itself more recently ; it was that of a man 
ill with pneumonia which had advanced to the period of suppuration, 
previously to his admission. This patient offered, during life, the signs 
of uncomplicated endocarditis ; there was a dull confused action of the 
heart, neither of the natural sounds being very distinct ; their rhythm was 
also somewhat changed. The impulse was diffused and labouring. 
There was but a very slight increase of the natural dulness on percussion, 
at the precordial region, and there was no creaking sound. I considered 
this case as one of endocarditis, without much valvular alteration, and 
mentioned my reasons for this diagnosis to several of you, who were then 
present. The patient died of the mingled effects of the pneumonia and 
the endocarditis, and, as you remember, we found the internal membrane 
of the heart reddened, as well as that of the orifice of the aorta ; it was 
covered with a delicate membrane that could be detached from it in strips 
of considerable length. On examination of this membrane by the aid of 
a magnifying lens, we found that it was apparently organised and traversed 
by numerous blood-vessels. 



LECTURE V. 

Tubercular meningitis — Case — Anatomical characters — Symptoms. 

I shall continue to-day, gentlemen, the subject of inflammations of the 
serous membranes, and take up the consideration of a case which came 
under your notice at the hospital, a day or two since, and presented an 
example of inflammation of the serous membrane investing the brain. 
We may the more properly enter upon the subject at this time, as it will 
facilitate our future examination of the diseases of the substance of the 
brain. 

The patient, of whom I have spoken, died in the ward No. 3, and was 
not under my immediate care. He was a carpenter by trade, and had 
suffered severely in early life from scrofulous affections ; both his feet had 
been ulcerated from this cause, some time previous to his admission. He 
also laboured under disease of the heart, and entered the hospital for hy- 
drothorax, the cavities of both pleuraB being filled with water, and suffer- 
ing under an extreme and distressing dyspnoea. He was relieved from 
these symptoms by salivation, combined with the use of digitalis and 
squill. He got rid of his shortness of breath, and was able to work in the 
out-wards of the establishment, w T here he continued, until the breaking 
out of the epidemic of measles, with which disease he was taken on the 
second of April. He suffered considerably from the measles, but gradu- 
ally became convalescent, till, on the twenty-eighth of April, he offered 
some symptoms of a cerebral affection ; that is, unusual dulness, stupor, 



TUBERCULAR MENINGITIS. 657 

and oppression. On the first of May, the cerebral symptoms became so 
well marked, that they were recognised as those of meningitis by the 
physician in attendance. At that date he was in the following condition. 
For two days previously he had manifested great restlessness, with occa- 
sional incoherence and hallucinations. Skin warm ; pulse full and strong, 
the bis feriens character, which attended his convalescence from measles, 
having ceased from the twenty-ninth of April. This bis feriens pulse, a 
frequent sign of convalescence from the measles, which was well marked 
in this case, ceased, you see, the moment he was taken with the new 
disease of the brain. The thirtieth, venesection §ix. ; the crassamentum 
of the blood was tolerably firm, and it was neither cupped nor sizy, about 
one-half of it being serum. The man at this time answered questions 
slowly. The conjunctiva was slightly injected. The tongue pale, moist, 
slightly furred. The pupils insensible to light, although he still recog- 
nised objects. No cephalalgia. The abdomen resonant ; not painful on 
pressure, except in the hypogastric and pubic regions, where it was also 
distended and flat on percussion. Percussion of the left side of the chest 
resonant, except in the precordial region ; respiration pure. Percussion 
of the right side resonant, but less so than the left. Impulse of the heart 
strong ; the first sound prolonged, attended with strong bellows-murmur 
in the neighbourhood of the nipple, the same character of the first sound 
observed between the second and third ribs ; the second sound rough- 
ened, and heard over an unusually large extent of the right side. A 
purgative of salts and senna was prescribed, and a blister to the nape of 
the neck, dressed with mercurial ointment. 

On the third the countenance was rather less dull than on the first, and 
he answered questions better : had been delirious the night before. 
There was some grinding of the teeth. The skin was moderately warm 
and hot. Pulse ninety per minute, and much smaller. Conjunctiva 
much redder ; a discharge of a small quantity of yellowish matter from 
the right eye. In the afternoon, there was some strabismus and increased 
stupor. An injection of oil of turpentine and castor oil w T as administered. 
and cold applied to the head. 

On the fourth there was very great stupor ; the eyes were closed, and 
the patient could not be roused to answer questions. The head was 
turned to the right side ; the right eye inflamed as before ; the pupil of 
the left eye smaller than yesterday. Pulse about eighty-five, irregular 
and moderately strong. Bowels opened three times by the injection. 
Abdomen supple, and not distended. Cold to the head continued; calo- 
mel, followed by senna and salts. The same day the man died. 

The symptoms here, you perceive, were not those which denote active, 
violent inflammation, but w T ere simply dulness of the intellect, stupor, with 
grinding of the teeth, &c. 

The treatment was commenced by a bleeding which would have been 
larger, if the previous disease of the patient had not rendered him too 
feeble to bear it, and was followed by purging, and an attempt to mer- 
curialize the patient, which latter failed, from the short time that elapsed 
between the administration of the remedies and the man's death. 

The following appearances were found in the brain twenty-four hours 
after death. 

Marked adhesion between the dura mater and the membrane beneath. 
The vessels of the dura mater were more congested than usual. In taking 
43 



658 GERHARD'S CLINICAL LECTURES. 

the brain from the cranium about two ounces of fluid escaped. The large 
vessels of the pia mater were much congested ; the capillary vessels of a 
bright red tint, — inosculating. In the middle part of the right side, the 
convolutions were flattened ; on this side, the injection of the pia mater 
extended to that portion dipping into the convolutions, and it adhered 
strongly to the cerebral substance. The injection and adhesions were 
less marked towards the posterior portion. At the anterior extremity, the 
arachnoid membrane was opaque ; the injection and adhesion somewhat 
less than at the middle. On the left side this bright injection occupied 
the middle half, and was confined almost exclusively to'the small arterial 
vessels. Pia mater less adherent than on the right side. Arachnoid 
slightly opaque, throughout the whole extent presenting a few minute 
granulations, near the parietal protuberance. The cortical substance on 
both sides was of a rosy tint, a little brighter on the left than on the right. 
That portion of the arachnoid covering the fissure between the hemi- 
spheres, and at the summit of the brain, was slightly roughened. Corpus 
callosum softened. Fornix and septum lucidum pulpy. The right ven- 
tricle was larger than the left ; the quantity of serum contained not known. 
The thalami and corpora striata were pale. At the base ofjhe brain, the 
colour was in a great measure lost, from the commencement of decom- 
position ; but in the whole anterior hemisphere injection of the small 
vessels was manifest. There were small adhesions between the anterior 
lobes of the brain. Fissure of Sylvius, on the left side, strongly adherent, 
by a solid deposit around the vessels, part of which, in the form of granu- 
lations, was still distinct. On the right side the same thickening occurred 
around the vessels, but the newly-formed matter was less abundant than 
on the left side ; it still presented tuberculous granulations, less in size 
than a pin's head. The arachnoid was opaque and extremely thickened ; 
the thickening of this membrane extended backwards over the chiasm of 
the optic nerves, which it slightly invested. Towards the cerebellum the 
thickening of the membranes became more marked at the upper portion, 
at the point of junction with the cerebrum ; the double secretion was there 
distinct, consisting, in part, of minute granulations, beneath the mem- 
brane, and in its thickness ; and, in part, of a thick, opaque, hard sub- 
stance, filling up the space between them. The cerebellum was firm, like 
the rest of the brain. 

There were no tubercles in the lungs, or the viscera of the abdomen. 
The state of the lymphatic glands was unfortunately not noted by the gen- 
tlemen who made the examination. From the former scrofulous disease, 
these glands were probably tubercular. 

It is to be inferred, then, that the disease of the brain was here of an 
inflammatory character, from the injection and thickening of the arachnoid 
membrane. It was evidently of the tuberculous variety, from the granu- 
lations which were found scattered beneath the arachnoid — it was a case 
of tubercular meningitis. The bright injection of the arachnoid, which is 
limited to the smaller vessels, is a very good diagnostic sign of inflamma- 
tion ; had it been observed in the larger vessels merely, I should have 
regarded it as a simple congestion. In the present instance we have, 
then, only the alteration in the membranes of the brain, to account for the 
cerebral symptoms, as the substance of the organ is not at all affected. 

This subject of tubercular meningitis, gentlemen, is one that will present 
itself frequently to your notice, as it is a disease very common with 



TUBERCULAR MENINGITIS. 659 

children, and by no means rare in adults. It is generally slow and insid- 
ious in its progress, and requires a very careful examination to distinguish 
it, particularly in its early stage. I have taken for the subject of some 
general remarks to-day on this disease, a case in which we have had 
the pathological phenomena very clearly presented to us, and in which 
the indications, previous to death, were sufficient for a correct diagnosis 
of the affection. This case, I may remark, exemplifies the occasional 
effect of measles, in giving rise to the development of tubercles, to which 
I alluded at my last lecture. 

This individual, we learned, had an attack of brain fever (so termed 
by his mother) many years ago, by which his mind was at the time con- 
siderably affected. This was probably a scrofulous inflammation of the 
same character as that which finally carried him off. Children may recover 
from these tubercular cerebral affections, and, at some subsequent periods 
of their lives, present the same symptoms in a more marked manner, from 
a new secretion or, as it were, second crop of tubercles in the membranes 
of the brain. So, patients may partially and temporarily recover from 
pulmonary phthisis, as was shown to you in a late autopsy, where co- 
existing with the cavities which immediately preceded the death of the 
patient, were distinct traces of the operation of a former cure, in the 
hardened cicatrices, which we found in various parts of the lung. The 
man whose case we are considering, had probably recovered from an 
attack of tubercular meningitis, early in life, and he might have remained 
well, had not the occurrence of measles awakened the slumbering tuber- 
cular disposition, and caused a fresh development of the affection which 
now proved fatal. 

This subject of tubercular meningitis I investigated very fully some 
years ago at the Children's Hospital at Paris, and obtained some impor- 
tant results as to the nature and cause of the affection. The first point of 
inquiry, upon entering on the subject, is, have we any evidence of the 
existence of tubercles, elsewhere than in the brain and its membranes, in 
this affection? In the children who died from this form of inflammation 
of the brain, I found tubercles in the bronchial glands or other organs of 
the body, as well as in the substance and membranes of the brain, where 
they were found from the size of a pin's head to that of a large pea. 

There was but one evident exception to this rule, out of thirty cases, 
that were analyzed in a paper, which I published in the American Jour- 
nal, in 1834. In the exceptional case, there were tuberculous granula- 
tions in the membranes of the brain, but not in other viscera. The coin- 
cidence of tubercles in various parts besides the brain conclusively proves, 
that a general tuberculous diathesis existed in these subjects, for in no 
other class of acute disease does the same rule obtain. In a few cases, 
however, the tuberculous deposit may not appear except in the membranes 
of the brain. 

Having determined the point as to the general tubercular nature of the 
disease ; the next matter to be investigated is, the causes on which de- 
pends the development of the affection. Unquestionably, the scrofulous 
diathesis is the strongest predisposing cause of this affection, using the 
word scrofulous as significative alike of the tubercular and strumous tem- 
perament. In almost all the cases in which the cerebral affection occurs 
in adults, a scrofulous disease has previously existed, and perhaps been 
cured in some other part of the body, as the lower extremities, the glands 



660 GERHARD'S CLINICAL LECTURES. 

of the neck, the lungs, and elsewhere. As to the exciting causes of the 
disease, they escaped us almost entirely ; in the majority of cases, at the 
Enfans Malades, we could detect no antecedent fact, which could at all 
account for the development of the tubercular disease of the brain. 

The measles, however, in the case under notice, is to be looked upon 
as the accidental cause of the development of the disease ; and I may 
make the general remark, that, whenever, in a scrofulous child, you have 
an acute disease accompanied w T ith fever, you may look for the develop- 
ment of inflammation of the brain, and are to watch your case with ex- 
ceeding care. 

The prognosis, in tubercular meningitis, must, generally, be more or 
less unfortunate, particularly in hospital practice. This deduction I base 
upon the observations made by myself and my friend Dr. Rufz, at the 
Children's Hospital at Paris, where, for one or two that got well, forty 
died. Indeed, Charpentier, who observed ten years ago in the same 
hospital, went so far as to say that he never saw one case recover. Yet, 
in private practice you will find the results much more favourable. In 
the hospital at Paris, the children were badly fed, confined in close rooms, 
and the treatment prescribed was not so minutely carried into execution 
as in private practice. I have not seen many children with this com- 
plaint since my return to Philadelphia, but those cases which I have seen 
were generally but not always fatal. A striking instance occurred in the 
child of one of our nurses ; she was a girl of four or five years of age, and 
recovered entirely, but a second attack came on, a year or more after the 
first, and proved fatal. 

The adults who are taken with tuberculous meningitis, nearly all labour 
under phthisis pulmonalis, which complication contributes not a little to 
the fatal termination of the affection. These cases are, of course, not fair 
standards for estimating the powers of treatment. In many cases, also, 
of this disease, the existence of tubercles in the lungs may not be ascer- 
tained during life, although they may be found after death. This was the 
case with a negro, whom I examined some years ago at the Pennsylvania 
Hospital. (See American Journal^ 1836.) During life he had neither 
cough nor expectoration, but I found, after death, numerous miliary tu- 
bercles in the lungs, as well as in the brain ; in other words, the man 
laboured under general acute tubercular disease, which, from similarity in 
the size and appearance of the granulations, must have commenced nearly 
at the same time in the lungs and brain, but had not attained a large size 
in either organ. Generally, we meet with the disease in adults, under 
circumstances that preclude the hope of a cure ; but, in children you may 
entertain a fair hope of success, if you see the case early ; if it has ad- 
vanced so far as the second stage of the disease, you have but a slight 
prospect of saving the child from speedy death. 

The symptoms differ in children and in adults. In adults, the disease 
appears in patients actually labouring under phthisis, or of a decidedly 
strumous diathesis; while it often shows itself in children, who are in the 
enjoyment of tolerably good health, notwithstanding some latent tendency 
to scrofulous diseases. Whenever, therefore, in children, the symptoms 
which I shall describe as characteristic of the forming stage of the disease, 
present themselves, the physician should put himself upon the watch, 
though they are not to be looked upon as invariably indicative of the 
result in question. Tubercular meningitis may begin in two ways : — 



TUBERCULAR MENINGITIS. 661 

First, it may come on abruptly, as ordinary acute meningitis, with vomit- 
ing, chill, and fever. The cerebral symptoms may appear, however, 
without even the prelude of vomiting ; in adults this symptom is com- 
monly wanting. When its approach is more gradual, the following order 
of phenomena is observed : — 

For the first few days the child merely evinces unusual restlessness and 
irritability, showing signs of excitement of the brain. He avoids light 
and sound, from the extreme sensibility of the eyes and ears. We have 
also a change in the intelligence, if the child be old enough to permit 
such attention to be noticed. First, it is simply excited ; the child is 
more lively and acute, and more attentive to external objects than before. 
Afterwards the countenance becomes changed ; the cheeks are flushed, 
the eyes unusually bright, and a well-marked frown and wrinkle are to be 
noticed on the forehead. This is one of the most important signs of the 
early stage of the disease ; and at this period, it is essential to recognise 
all the symptoms, and this peculiar expression you may consider charac- 
teristic. This, together with the bright red flush upon the cheek, the 
nurses in the Children's Hospital used to look upon as an unfailing mark 
of the approach of the disease. The decubitus is at this time but slightly 
altered. But we often meet with some secondary symptoms, which, al- 
though they are not always present, are of some moment ; these are nau- 
sea or vomiting, constipation, and fever, which is at first of a mild cha- 
racter. 

We now pass to the second stage, comprising the symptoms which 
were first observed in the man who had just died ; those of the forming 
stage were lost in the decline of the measles. These symptoms are deli- 
rium, which cannot of course be very accurately observed in children, 
particularly if they are very young. But some signs of itjuay be gene- 
rally detected, especially at night, in the quick answers and altered man- 
ner of the child. This delirium differs from that of ordinary acute menin- 
gitis, in which the patient is violent, noisy, and loquacious. Here there 
is mere dulness and stupor, somewhat similar to the delirium of typhus 
fever ; the child is not very violent, makes no efforts to walk about or to 
do mischief, but remains in a state of dull muttering. 

I was impressed by this peculiarity of the delirium of tubercular menin- 
gitis, in two cases which came under my observation at the Pennsylvania 
Hospital three years since. In one, of so moderate a character was the 
delirium, that the patient was admitted for simple insanity. The only 
other symptoms that attracted attention, upon his admission, were a pecu- 
liar hobble and limp in his gait. We found the traces of several scrofu- 
lous disorders, which had been cured, and the man had also a slight 
cough, of which he had complained for two years past. The patient was 
constipated before his* entrance, and shortly afterwards vomiting ensued, 
and then the cerebral symptoms became more decided. The paralysis 
occurred very early, from the coincidence of softening and inflammation 
of the substance of the brain with that of the membranes. 

At first, in fact, I thought it was paralysis, from mere softening of the 
brain. Afterwards, I began to doubt, and regarded the case as one of 
tuberculous meningitis: finally, the autopsy cleared up all obscurity. 
The paralysis was found to be dependent on softening of the brain, and 
the delirium arose from tubercular meningitis with effusion of lymph at the 
base. This complication of lesions necessarily gave rise to the intermix- 



662 GERHARD'S CLINICAL LECTURES. 

ture of the symptoms of meningeal with those of cerebral inflammation ; 
in practice this coincidence is by no means rare, and it is not often diffi- 
cult to detect it. The seat of the disease was here the same as in the 
case of the man Crane ; the deposit of tubercles was along the blood- 
vessels, following the ordinary law which regulates the secretion of tuber- 
cular matter. 

Besides the delirium of the second stage, we meet with alteration of the 
senses, as in the case of Crane. The pupils are generally dilated, mode- 
rately and gradually ; in some cases, they are contracted, but, as was ob- 
served by Dr. Stewardson in the present case, it is difficult to tell if they 
are permanently contracted, being at one time contracted, and at another 
dilated. These alterations of the pupils are most important signs, parti- 
cularly when accompanied by the muttering delirium. 

Lesions of motility next present themselves. These consist at first 
principally in subsultus or even spasms, as in typhus fever ; indeed I have 
sometimes hesitated for a little while in my diagnosis, between the two 
affections. Paralysis is by no means a necessary symptom in the second 
stage of meningitis. But we have then the beginning of another symp- 
tom, rigidity. In the case of a man now in the wards, this stiffness could 
be detected only by careful examination of the elbow, but it may be 
usually very early ascertained with proper caution. This rigidity differs 
from contraction, which is a more advanced degree of it, and is more 
rarely met with in this form of meningitis. Rigidity is not here confined 
to one side of the body, as in apoplexy and softening of the brain, for the 
tubercles are secreted, on both sides of the base of the brain, and, hence, 
the symptoms of disease of the membranes are rarely confined to one-half 
the body, while those of the cerebral substance are as rarely extended 
beyond it. 

These are the chief cerebral symptoms of the second stage of the affec- 
tion. We now pass to another set, those of the digestive organs. Vom- 
iting is one of the most constant symptoms of tubercular meningitis in 
children, but it rarely continues beyond the first stage. Another peculiar 
and important symptom is constipation. In the second of the two pa- 
tients in the Pennsylvania Hospital, to whom I have alluded, the case 
was at first looked upon by his physician as one of simple constipation ; 
and the true nature of the complaint was suspected only when it was found 
that the symptom did not yield to purging. This gives us a valuable 
therapeutic indication, in the treatment of the affection — that is, the pro- 
priety of purging. The appetite is generally lost from the beginning of 
the affection. The thirst is in proportion to the degree of fever present. 
The state of the pulse may be learned from the case of Crane. In him, 
the bis feriens pulse, of 60 and 66 per minute, existing during the con- 
valescence of measles, rose at once to 90 3 and continued at this point till 
the third stage, when it sank again to 85. It was therefore simply febrile 
in the second stage, and irregular in the first and third. It is rarely slow, 
and slowness may be looked upon as a good symptom, except in the third 
stage. 

The other symptoms are less significant in their character, and I would 
merely refer you to the memoirs which I published in the American Jour- 
nal, in the years 1834-5. 

In the third stage, or after effusion of serum, pus, or lymph has taken 
place, the ordinary termination of serous inflammation, to which I called 



TUBERCULAR MENINGITIS — TREATMENT. 663 

your attention in my last lecture ; we have a subsidence of the acute 
febrile disturbance, the pulse is often preternaturally slow, coma comes 
on with partial paralysis from the pressure of the effusion, which is not 
necessarily confined to one side of the body, and is slow and gradual in 
its advances. 

I have given you merely a slight sketch of the pathological anatomy of 
this affection, as I do not, in this course, intend to dwell, at any great 
length, upon this subject. The treatment of tubercular meningitis, to the 
consideration of which we now pass, involves many important questions. 
It must vary, according to the severity of the actual symptoms, and the 
circumstance of the existence of a previous tubercular disease. If the 
patient is in the third stage of phthisis pulmonalis, you can of course do 
little or nothing. If this be not the case, however, you may, I think, do 
much. The case must be at first treated as one of simple meningitis. 
Your object should be to get rid of the acute inflammation of the brain, 
which increases necessarily the disposition to tubercular secretion, and 
may at once kill the patient. You must not, however, deplete to the 
same extent that would be advisable if there were no tubercular deposi- 
tion. You are to steer a middle course. My plan is to resort to blood- 
letting, general and local, unless the development of tubercles be very 
far advanced. I have recourse to general blood-letting once, and once 
only, even in adults. It is an old remark of writers, that inflammations 
of the membranes of the brain generally bear excessive depletion worse 
than those of other organs, but always tolerate well the local ab>traction 
of blood. Local bleeding is to be directed, so long as the patient can 
bear it, that is to say, until he becomes pale, and the rlu^ is gone, 
whether the other symptoms abate or not. After depletion, I was formerly 
in the habit of placing blisters to the back of the neck. I am now in the 
practice of applying them behind the ears. The discharge can here be 
kept up longer, and will act more steadily, and the sore can be better 
dressed ; the patient may be mercurialized by dressing these blisters with 
mercurial ointment. The discharge by the blisters I keep up, until the 
patient is perfectly well. Another remedy is counter-irritation elsewhere 
than near the head. The feet are apt to be cold ; they are to be plunged 
into hot water from time to time, to be clothed with flannel, and rubbed 
occasionally with cayenne pepper. But you are to abstain from further 
blistering ; it only serves to create fever, and is generally mischievous. 
Sinapisms may be used, but the surface is not to be vesicated. 

The next remedy to be employed is purging. If the patient be strong 
and robust, it answers a very good purpose, and in a few rare cases at once 
relieves him. But in children, if relief be not afforded by one or two pur- 
gative doses, it is proper to be cautious as to their employment. With 
children I begin with a mercurial purge, from four to eight grains of calo- 
mel, to be followed by a saline purgative, or, still better, some castor-oil. 
Mercurials are used by the French merely for the purpose of purging ; of 
course they do not salivate, and, when persisted in, do no good. As soon 
as the acute stage of the disease has abated, you must commence with 
mercurial dressings and frictions of the abdomen. These are of most ser- 
vice in the sub-acute variety of the disease. 

I have now detailed you the ordinary practice to be observed in the 
management of tubercular meningitis. To one or two points your atten- 
tion is to be particularly directed. You must carefully watch the moment 



664 GERHARD'S CLINICAL LECTURES. 

when it is proper to stop blood-letting, and immediately after commence 
the introduction of mercury into the system, and continue it until the active 
period is past. 

After the third stage of the disease is established, and paralysis makes 
its appearance, treatment can do no good. The affection is then fatal, be- 
cause the functions of the brain are so much interfered with that the pa- 
tient must necessarily perish. 

Tubercular serous inflammations are not elsewhere so fatal, as when they 
occur in the membranes of the brain. When secondary peritonitis and 
pleurisy destroy life, death usually follows from perforation of the glands 
of Peyer, or perforation of the lungs. 

The tuberculous inflammations of these membranes, however, assume 
a much higher importance from their tendency to return and even to at- 
tack other portions of the body. Besides, they certainly favour the de- 
velopment of tubercles, in cases in which the patient had previously pre- 
sented merely the signs of the diathesis which precedes this morbid de- 
posit. For a more complete account of this connection, I must refer you 
to my lectures on pathological anatomy. 

The symptoms and treatment of tuberculous meningitis you will find 
detailed in the memoirs which I published in the American Journal, in 
the years 1834-5, as well as in the paper of my friend, Dr. Rufz. 



LECTURE VI. 

Peritonitis fiom cancer of liver — Acute Meningitis — Diagnosis — Symptoms — Treatment. 

It is my intention, to-day, gentlemen, to continue the discussion of in- 
flammations of the serous membranes, with particular reference to the sub- 
ject of meningitis. Previously, however, to entering upon this latter topic, 
I shall call your attention to a case of serous inflammation, which termi- 
nated, a day or two ago, at the hospital, and at the post-mortem exami- 
nation of which most of you were present yesterday morning. We had, 
you recollect, acute peritonitis, pervading the whole of the abdomen, the 
result of a chronic disease of the liver. This disease of the liver was sus- 
pected, during the lifetime of the patient, there being sufficient evidence 
of the enlargement and hardening of the organ. The nature of the affec- 
tion we found to be cancerous; rounded deposits having the anatomical 
characters of vascular sarcoma, were scattered throughout the substance 
of the liver, offering very fair specimens of this variety of soft cancer. I 
shall not now enter into an examination of the subject of cancer, but shall 
confine myself to the acute inflammation of the serous membrane, which 
was induced by the carcinomatous disease. This case of secondary peri- 
tonitis exemplifies the law I enunciated to you, at a previous lecture. 
Serous inflammations, with the exception of those of the membranes of 
the brain, are not very dangerous, unless they occur as secondary to a 
primary lesion of an organ, or are connected with a cachectic state. This 
secondary inflammation, which is very frequent in the peritoneum, may 
be either acute or chronic. In the present instance, it was acute, and, 
probably, arose from the cancerous tumours approaching the surface of the 



ACUTE PERITONITIS. 665 

liver. Examples of the chronic secondary inflammation of the peritoneum 
are most frequent in phthisis, when they are connected with a tuberculous 
deposit in the serous membrane itself, as was demonstrated to you in one 
of my last lectures on pathological anatomy. 

In the present instance the peritonitis was acute ; it was only within 
the last two or three days of the patient's life that he was seized with 
acute pain over the whole of the abdomen, accompanied with great ten- 
derness on pressure. A tumour was distinctly felt, which I described to 
you as similar to the pointing of an abscess, and induced me to suspect 
the presence of suppuration. After the occurrence of the acute pain, the 
patient sank rapidly, without any other of the usual symptoms of perito- 
nitis, as vomiting, &c, but his prostration was extremely great. Pros- 
tration of this character is a striking symptom of the secondary serous in- 
flammation of the peritoneum, and is a most valuable sign in leading us 
to our diagnosis. You have seen it before in a case of pericarditis suc- 
ceeding gangrene of the lungs, and also in the case of a black man affected 
with tuberculous pleurisy. Whenever you have sudden and extreme 
prostration, supervening upon a chronic disease, in any of the great 
cavities, you may suspect the existence of secondary inflammation of their 
serous coats; but it is much more intense in peritonitis than in pleurisy 
or pericarditis. This was the character of the tubercular peritonitis, de- 
pending on perforation of the intestine, noticed in a preceding lecture ; 
and I have, at other times, pointed out to you instances in which there 
was the same kind of perforation into the cavity of the pleura, following 
ulceration of the lungs. Perforation is by no means necessary to the pro- 
duction of these secondary inflammations of serous membranes ; in the 
case now before us, the exciting cause was the irritation of the cancerous 
masses in the liver, but just beneath the peritoneum. The same disease 
may occur in the ovaries, uterus, and other parts, producing similar 
results. 

Another example of secondary peritonitis is the affection, generally 
designated as puerperal fever, a term which is now usually limited to 
peritonitis, although some physicians are still in the habit of including all 
febrile diseases of women in child-bed under this head. It is imperative, 
however, to distinguish between these affections. The true secondary 
peritonitis of puerperal women depends upon the inflammation of the 
uterus or its veins, or else upon the irritation consequent upon delivery ; 
but it is rendered more frequent and more severe by the strong tendency 
to suppuration, which extends to all the membranes and organs of puer- 
peral women, and gives rise to the various affections which are sometimes 
called puerperal fever. 

The anatomical signs in this case were similar to those observed in the 
other cases of serous inflammation, which have come under your notice 
just now, from their great prevalence in spring and the beginning of 
summer. Thus, to study pathology, you see how necessary it is to pass 
through seasons and even cycles of disease. In these serous inflamma- 
tions, you see how interlocked they are with all other diseases, occurring 
sometimes as idiopathic, but in the large majority of cases as secondary 
affections; the first class being rarely fatal, except w T hen attacking the 
membranes of the brain. Continuing the subject of special serous inflam- 
mations, I shall now proceed to take up the subject of meningitis. 

Meningitis may be easily confounded with other affections of the brain. 



666 GERHARD'S CLINICAL LECTURES. 

We had a case a few weeks ago, of a surgical patient, affected with dis- 
ease of the urethra, in which it was with some difficulty that we made 
out, even after death, a satisfactory diagnosis, the point being settled with 
certainty, only by the presence of a slight quantity of pus. I was called 
to the case, a short time before the man's death, when the only striking 
symptom was delirium, which I looked upon as merely the concluding 
act of life. The true nature of the affection was, however, revealed by a 
post-mortem examination. We found, first, a bright injection of the pia 
mater, which is characteristic of inflammation, particularly if there be no 
serum present. Injection of the large vessels is not indicative of inflam- 
mation, but merely of congestion ; the two not usually co-existing to- 
gether — a bright arterial tint denoting the one, while the other gives a 
dark blue colour to the surface implicated. The injection was in this 
case spread over the whole surface of the membrane ; this is generally 
the case, although it predominates at one portion, either the base or the 
summit of the brain. Here, the inflammation was most evident at the 
summit, involving the faculties of the intelligence ; while, in children, it 
usually occupies the base and is connected with a disturbance of the 
senses. The distinction I make here, coincides with one, of the leading 
points of phrenology, which allots the faculties of the intellect and of the 
senses to different portions of the brain.- Although I look upon the details 
of this science as still founded only upon the imagination, yet the great 
fact, that the intellect is connected with the summit, and the senses with 
the base of the brain, is unquestionably true, and confirmed by patholo- 
gical observations. 

The roughness of the serous coat, the arachnoid membrane, is the next 
point to be noticed in this case. It might seem, that mere effusion of 
liquid would be enough to characterize inflammation of this membrane. 
This is not so, however ; when it is in a healthy state, there exists a 
liquid, which is clear and transparent, but in the early stages of real in- 
flammation, it becomes altered in quality and deficient in quantity. The 
inflammation is not so much that of the arachnoid membrane as of the 
subjacent pia mater, in the meshes of which the morbid products are 
chiefly retained. True inflammation of the arachnoid is of very rare oc- 
currence. In the present case, we found pus mixed with lymph in the 
pia mater, giving a yellowish appearance to the membrane. The three 
great pathological features, then, of this case, from which we concluded 
that it was one of acute meningitis, were the injection of the small vessels 
of the arachnoid, the roughening of this membrane, and the deposit of 
lymph and pus beneath it. 

The consideration of this case offers another point of much interest — 
the connection between affections of the urinary organs and diseases of 
the brain. Ten years since, my attention was first directed to this sub- 
ject, upon observing a man labouring under stricture and thickening of 
the lining membrane of the urethra, to my great astonishment, perish 
suddenly from cerebral symptoms. At the Pennsylvania Hospital, two or 
three years ago, I noticed the death of a man from similar symptoms of 
disease of the brain, after a few days' illness, who had been previously 
suffering from inflammation of the neck of the bladder and urethra. 
Various writers, and particularly Lallemand, have called attention to this 
subject. Dr. Lallemand has dwelt, especially upon the connection be- 
tween diurnal seminal emissions dependent upon chronic inflammation, 



ACUTE MENINGITIS. 667 

and the development of cerebral disease. The cases of this character, 
described by Lallemand, he usually traced to gonorrhoea, which, occa- 
sioning a thickening of the neck of the bladder, the vesiculaa seminales, 
and the ductus ejaculatorius, left the latter in a patulous condition, allowing 
a discharge of semen to take place without ejaculation, during the acts of 
urining or fecating. The dependence of cerebral disease upon causes of 
this nature, is therefore a highly important fact, which will assist you in 
understanding some affections Otherwise not easily explicable, for the 
seminal weakness, of long continuance, enfeebles the understanding, and, 
finally, the brain is disordered to such an extent, that medical relief is 
sought for. I have had several cases of this character, in which the 
affection was supposed to be connected with a nervous temperament, and 
was, in short, referred to various other causes than the correct one, but, 
in every instance, I was able to make out the previous existence of chronic 
gonorrhoea, producing the condition of the urino-genital organs which I 
have described, and, through this means, giving rise to functional cerebro- 
nervous disturbance. At first this is purely nervous, but after it has lasted 
for a few days it may become inflammatory. When the nervous disease 
is replaced by the organic one, you will find that the symptoms become 
much more permanent, and more or less paralysis soon follows. M. 
Lallemand treats these affections by directing his remedies to the urinary 
organs. 

In the case of the man at the Pennsylvania Hospital, to whose death, 
with cerebral symptoms, I have alluded, we found upon examination after 
death the vesiculae seminales and ductus ejaculatorius destroyed ; an 
abscess behind the verumontanum, filled with pus ; and the coats of the 
bladder contracted and thickened. The particular history of the case was 
not taken, but it illustrates finely, how chronic diseases of the urethra 
give rise to affections of the brain : and how causes, trivial in themselves, 
may produce serious and fatal functional disturbances. Death, to use the 
words of M. Lallemand, may be the result of a series of illnesses, dating 
their origin from an attack of gonorrhoea ; which is in itself an insignificant 
affection. 

From this digression, I return to the subject of inflammation of the 
membranes of the brain. The case of the man Brown, which has been 
under your notice for some time past, at the hospital, will serve as a fair 
illustration of the subject. We have no example in the hospital of acute 
meningitis, but the case of Brown, which is of the sub-acute form, being 
more slow in its progress, and better marked in its character, will very 
properly serve as introductory to the study of the acute type of the dis- 
ease. This man was taken ill with cephalalgia, in the region of the fore- 
head and frontal sinuses. We inferred, as we had a right to, that it was 
not a case of secondary meningitis, from the absence of any previous ill 
health. Soon after the commencement of the headache, the senses became 
implicated ; the sight of the left eye was impaired, and the hearing was 
disturbed with tinnitus, buzzing, resembling the noise produced by a saw, 
and as the affection declined, it was like the humming of bees. These 
comparisons are the patient's own expressions, and were not elicited bv 
any leading questions ; they are, therefore, the more descriptive of the 
symptoms. With the advance of the disease, there were dulness, sadness, 
and somnolency, but no delirium. There was contraction about the eye- 
brows and the root of the nose, forming, as I mentioned when noticing 



668 GERHARD'S CLINICAL LECTURES. 

this symptom in the lecture on tubercular meningitis, one of the best 
marked signs of meningeal inflammation. The contraction was, in this 
case, of a permanent character, and would have enabled any one, at all 
accustomed to the affection, at once to recognise it. There was no para- 
lysis ; no subsultus. The inflammation was confined to the anterior and 
inferior parts of the brain, not extending to the summit, as the faculties of 
the intelligence were but little impaired, nor was there much lesion of the 
cerebral substance, for there was neither paralysis nor rigidity. 

After establishing the symptoms, the question starts itself, with what 
affections might this case be confounded? With very few. First, it 
could not be acute meningitis. The tongue was natural, and, although 
there w T as some constipation, there was no nausea or vomiting ; there was 
no cough ; nor was there any unnatural excitement of the pulse, and no 
dreaded delirium or intense excitement of the brain. The inflammation 
was then limited to a small spot of the brain, for had it been more ex- 
tended, the pulse must have shown it, by becoming unduly excited. 
The same absence of paralysis which showed that there could be but little 
cerebral lesion, would indicate that the disease did not depend upon 
large tubercles, or other chronic tumours of the membranes, for these 
lesions speedily produce palsy. By way of exclusion, therefore, we suc- 
ceeded in localizing the affection, and we recognised meningitis attacking 
the anterior portion and base of the brain. In addition to its anti-febrile 
character, its course, which lasted a month, a much longer duration than 
belongs to the acute form of the affection, and its gradual decline, satis- 
factorily demonstrated its sub-acute progress. 

The prognosis was an important point, which came up for discussion, 
at the period of the man's entrance into the hospital. It was at first 
doubtful; was the menirrgitis secondary, and dependent on the presence 
of a tumour or tubercles, or the like ? After the lapse of two or three 
days, it was clear that there was no chronic disease, but that the affection 
was a mere local phrenitis or meningitis. We made our minds up to this 
conclusion, from the evident absence of all symptoms of an impaired con- 
stitution. The man had not been ill before the time of his recent attack, 
he had never called for the aid of a physician, nor had his friends ; I say 
his friends, because in chronic cerebral affections the patient himself is 
often afraid to call attention to his symptoms, and the first application for 
medical relief is on the part of his friends, as the evidence of some de- 
cided mental aberration or change of feeling or habits is forced upon them. 

The treatment proper in acute meningitis is sufficiently well exempli- 
fied by that pursued in this case. There are certain great laws well laid 
down for the management of this affection, which are much more clearly 
understood than the subject of therapeutics in general, owing, I think, to 
the fact, that close observation is more easy in meningitis, from its rapid 
and well-defined symptoms, than in diseases of the thorax or abdomen. 
The following are the points to be attended to in treating acute meningitis. 

Blood-letting, in patients who give evidence of tolerable strength, em- 
bonpoint, and previous good health, is always advisable ; but in the acute 
form of the disease, depletion becomes a measure of absolute necessity, 
and, if it be neglected, your chance of saving your patient is but small. 
Should your bleeding be large or small ? It is best to take a considerable 
quantity of blood at once from the patient, if he be a stout and healthy 
man ; you may thus, sometimes, immediately arrest the disease. When 



ACUTE MENINGITIS. 669 

serving in the Pennsylvania Hospital, I had a case illustrative of the good 
effects of this practice, and of the great importance of a correct diagnosis 
in cerebral affections. A man was brought into the cells, said to be 
labouring under mania a potu : he was a sailor, who had just made a 
voyage from Boston ; he had been drinking to excess, but had also been 
working hard, exposed to a very hot sun. Upon examination, I found 
the signs he exhibited to be not those of ordinary mania a potu ; his head 
was hot, his pulse quick, in short, he was in the first stage of acute inflam- 
mation of the brain. I bled him largely, between twenty and thirty ounces, 
and he was, I may say, instantly cured. It is true, that the next day I 
directed a slight cupping, a purge, and the like, but they were merely by 
way of precaution. Had this patient been treated by opiates as a case of 
mania a potu, he must almost infallibly have died. Such cases I have 
seen treated in this manner in hospitals, for so common a vice is drunk- 
enness in this country, that all diseases of the brain occurring in intempe- 
rate persons are apt to be indiscriminately regarded as the effects of ex- 
cessive indulgence in ardent spirits. When I was a resident physician in 
the Aims-House Hospital, a woman was brought in with a fracture of the 
skull, upon which arachnitis supervened. She was treated as a case of 
mania a potu, by a gentleman who was writing a thesis on this subject ; 
his mind was consequently absorbed by this single variety of cerebral 
affection, and a most unfortunate error was committed. She died ; ami 
upon examination after death, spiculae of bone were found driven in upon 
the dura mater ! 

After you have bled once largely, it is best to limit a repetition of gene- 
ral bleeding to cases of individuals of a very plethoric habit. In place 
of general depletion, keep up cupping and leeching, which, if persisted 
in with regularity, will do much good. As to cupping, every thing de- 
pends upon the manner in which it is applied. In the case of Brown, all 
the cuppings were of service except one, when the cups were applied to 
the temples ; here it seemed only to augment the irritation — the pressure 
of the cups very near the seat of disease causing an afflux of blood to the 
part. The cups, which were applied to the back of the neck, all did 
good. I do not speak of cups to the forehead, because nobody thinks of 
using them in that quarter. My advice, then, is to cup rarely to the tem- 
ples, and generally to the back of the neck ; leeches behind the ears may 
be employed with much advantage ; in this very case, I found leeching 
behind the ears of service, when the cupping ceased to do good, showing 
the mere change in the manner of abstracting blood to be of essential im- 
portance. Leeching, then, is to be sometimes resorted to, though cups 
are generally to be preferred in taking blood locally, from the ease with 
which the quantity may be regulated, and the facility with which they 
may be applied ; but if you find the patient very excitable, leeches are 
much more certain than cups, and relieve more with the loss of a less 
quantity of blood. 

In very acute meningitis, you have within your control another power- 
£il remedy, and one that is quite as important as any of the others — ice 
to the head. It is to be applied with caution, and you are to judge of its 
producing an effect by the supervention of faintness, languor, or paleness 
of the face. In hospitals, the ice may be applied in a tranquillizing chair, 
but in private practice, where you have no such convenience, a bandage 
with a bladder of pounded ice may be employed for this purpose ; you 



670 GERHARD'S CLINICAL LECTURES. 

must be careful to renew the application as soon as the ice melts, other- 
wise the alternation of heat and cold thus produced may do harm. The 
use of ice I would continue for several days, until there was a decided 
abatement of the acute symptoms. It is a great point in the management 
of this disease, to have for the patient proper attendance of persons who 
can control him. For this purpose one, two, or three men nurses will be 
indispensable in private practice, where those means of restraint are want- 
ing, which are to be met with in lunatic hospitals. 

The next remedy I shall mention acts on the same principle as the last, 
and is intended to produce revulsion from the head ; it is the application 
of warmth and stimulating poultices to the extremities. I was treating a 
patient some time ago with ice to the head, in whom, although the ice 
was evidently doing good, it produced pallor and languor, and the symp- 
toms abated but little ; upon examination, finding the feet cold, I directed 
warm stockings to be put on them, had sinapisms applied, and ordered 
them to be occasionally plunged into warm water, which was followed 
by an evident amelioration of the symptoms. Unless you attend to these 
precautions, yon will lose much of the good that may be derived from the 
application of cold to the head. Upon trifles like this, success in a great 
measure depends in the management of this affection ; indeed in thera- 
peutics the advantage which one practitioner has over another, depends 
chiefly upon his attention to minute and seemingly unimportant details. 

Although it may be somewhat irrelevant, I cannot here forget to caution 
you against falling into those habits of careless and hasty prescribing, 
which are sometimes produced by a negligent attention to the practice of 
public institutions. The advantages of hospitals are inestimable to one 
who uses them in a right spirit; that is, as schools of diagnosis, and of 
the great therapeutic indications. But you must remember that in pri- 
vate practice you must carefully direct or even superintend in person, a 
multitude of details, which are usually attended to in hospitals by well- 
trained nurses, aided by the system which exists in all well-conducted 
institutions. 

Much of the reputation of Dr. Physickas a practical physician, depended 
on a strict attention to these minuter points of detail, and he had, there- 
fore, often better success in the management of even medical cases, than 
persons who were perhaps more familiar with pathology, but not equally 
attentive to these particulars. 

Purging is a remedy which has been almost from time immemorial 
adopted in the treatment of acute inflammations of the brain. The saline 
purgatives combined with senna, or a mercurial purge, are those generally 
employed. I prefer a mercurial purge, as it serves a double object, by 
acting on the liver, and preparing the way for ptyalism, if it should after- 
wards become necessary ; it is besides a good preparation for the saline 
articles. I would begin by ten grains of calomel, followed up the next 
day by a dose of salts and senna ; should the calomel not purge, it will 
salivate, which is not to be dreaded. After, at least, a single mercurial 
purge, you may give doses of senna and salts, — a robust patient will re- 
quire half an ounce of each ; these, by inducing serous discharges from 
the bowels, will have a derivative effect. Afterwards your object should 
not be to produce violent purging, but to keep up a moderate looseness 
of the. bowels. 

Should the delirium not yield to depletion and purging, these remedies 






ACUTE MENINGITIS. 671 



should not be continued after the strength of the patient begins to decline, 
but you must now have recourse to mercury in small doses, and to blis- 
ters. Mercurials, like tartarized antimony, act as antagonists to inflam- 
mation, and may with propriety be employed in the second stage, or in 
the subacute form of the affection. They would have been highly appro- 
priate in the case of Brown, in whom we should have prescribed them, 
had the disease not yielded in the first instance to the local depletory 
treatment. It is best to continue the use of mercury until ptyalism is pro- 
duced. By effecting this, I have succeeded in curing a large proportion 
of the cases which have occurred in my wards of the hospital. An in- 
teresting case happened last summer, which, perhaps, some of you may 
recollect. It was that of a young man who had been a clerk at Mobile, 
and who on his way to Philadelphia, by the Mississippi river, had been 
taken ill with fever and delirium at Cincinnati, from which he recovered 
with difficulty. He came to Philadelphia not quite well, having still 
some symptoms of cerebral disease. He was taken ill again and brought 
to the hospital. He was then in a state of high cerebral excitement, being 
occasionally rational, and relapsing again into delirium ; throughout the 
night he would be in a state of great liveliness, loquacious, restless, with 
his senses considerably excited. From the history of the case, I con- 
cluded it to be one originally of acute meningitis, which had now become 
chronic, and began the treatment of it with blisters and local depletion, 
but the delirium did not yield, until a mild mercurial course was pre- 
sented. Another case I may mention was that of a young sailor, who 
was taken ill under circumstances which I do not now recollect. He had 
pleurisy first, and afterwards meningitis, and the disease did not abate 
till after a mercurial course. The symptoms were not the violent deli- 
rium of the last-mentioned patient, but mere stupor, dulness of the senses, 
and constant disposition to throw his head strongly backwards. Neither 
of these cases was dependent on the presence of tubercles or other chro- 
nic lesion. 

We come next to speak of blisters, which, it might seem at first sight, 
would be proper at an earlier period of the affection. This is not the 
case, however ; in the first stage they seem only to irritate, and decidedly 
augment the extreme agitation and violent delirium ; they should be de- 
layed till the acute symptoms subside, when they may be applied over the 
occipital region, extending to the back of the neck. They are to be 
rarely applied over the whole scalp, where they give great pain. The 
same law that regulates the employment of leeching or cupping is appli- 
cable here ; the blisters do more good at some distance from, than im- 
mediately over the inflamed portion of the brain ; when the disease is 
more chronic, it is often useful to keep a blister discharging behind each 
ear, as I have already advised in the treatment of acute hydrocephalus. 

Caustic issues or incisions over the fontanelles have been recommended 
in chronic meningitis, but as they are very inconvenient, they have not 
been generally used, though I see no reason why they should not be em- 
ployed in certain cases, especially where there is reason to apprehend that 
the disease has followed an injury of the head. 

The plan of treatment which I have given will succeed in curing the 
majority of cases of acute meningitis. If, however, the affection should 
not yield, and passes into the chronic state, the patient remains necessa- 
rily more or less insane, and is apt to sink into the third stage of insanity 



672 GERHARD'S CLINICAL LECTURES. 

or dementia. He becomes utterly incoherent, and the case usually ter- 
minates in a very curious but totally incurable variety of paralysis, called 
the paralysis of the insane. 

In the beginning of this kind of insanity, when the appearances of 
active inflammation have in a great degree subsided, cold affusions upon 
the head, repeated several times daily, mild laxatives, a sparing diet, ab- 
stinence from all excitement or exposure to the sun, with gentle exercise, 
prove the most useful remedies. In short, the treatment must be ex- 
tremely mild, but persevere while a hope remains of saving your patient 
from the worst species of insanity. 

When acute meningitis is fatal, the patient generally dies at the end of 
the second, or in the third stage of the disease, or he may die from me- 
ningeal apoplexy. I have twice or thrice seen a patient in the Aims- 
House, labouring under meningitis, become suddenly comatose, with 
stertorous breathing and loss of power of the limbs. The symptoms were 
those of apoplexy, arising from effusion of blood, not into the substance 
of the brain, but on the surface of both hemispheres into the membranes, 
which, from its pressure, is therefore necessarily fatal. 

Whether the inflammation of the membranes of the brain be acute or 
not, as soon as the third stage, or that of effusion of lymph or pus super- 
venes, the delirium becomes less violent, the disturbance of the senses is 
succeeded by a total abolition of them, the patient neither seeing nor feel- 
ing. There is a gradual supervention of paralysis ; sudden dilatation of 
the pupils in place of alternate contractions ; and there is usually, but not 
always, strabismus. This stage is necessarily fatal, there being no possi- 
bility of a recovery. 

To recapitulate briefly the course of my remarks to-day — you have had 
your attention called to the anatomical characters of certain serous inflam- 
mations, and after tracing the connection between cerebral affections and 
those of the genito-urinary organs, I have entered at length into the treat- 
ment of acute meningitis, basing my remarks upon a case of the sub-acute 
variety which has been lately under notice at the hospital. I have not 
gone into more details of the symptoms of acute meningitis, waiting till 
they present themselves to our notice, which, from our knowledge of the 
course of these affections, must be the case during the summer. The sub- 
acute variety is the only one which I am now able to demonstrate, by 
reference to a case actually under your notice. 



LECTURE VII. 

Chronic meningitis — Apoplexy — Paralysis of the insane. 

At my last lecture I continued the subject of inflammations of the brain, 
dwelling particularly upon that of acute meningitis, which I was able to 
illustrate by a case of the sub- acute form of the affection, at that time 
under your notice at the hospital. I merely alluded at the time to the 
subject of chronic meningitis, without entering into it at any length, and 
I, therefore, propose now to say a few words upon it, as it properly be- 
longs to this period of my course. We have a large number of cases of 



CHRONIC MENINGITIS. 673 

this affection in the wards of the hospital. I shall select the best marked 
of them, that of Urweiler, a German, to whose history and symptoms I 
shall briefly call your attention. This man, two or three years ago, 
having previously enjoyed good health, received a blow on the head, the 
effects of which, at the time, were not very seriously felt. He suffered slight 
headache, pain, &c, which, however, soon abated. But, after a lapse of 
time, the powers of his mind began to fail, and he became, finally, entirely 
deranged, and in addition to this disorder of the intellect, paralysis is 
gradually supervening. This latter symptom, as you may have observed 
in the hospital, is a very common accompaniment of insanity, chiefly of 
dementia; it is, however, often met with in persons in whom insanity i- 
not yet developed, the functions of motility being; attacked before the 
intellect is much impaired. The disease is, therefore, often to be recog- 
nised at first by the mere disorder in the powers of movement, and may 
ordinarily be detected as follows. Slight symptoms of mental aberration 
are presented, often not well marked, but, again, rapidly becoming strongly 
characterized, and running into the worst degree of madness — incoherence. 
The organs of locomotion become also affected, the first symptoms being 
a failure in the power of walking ; but feebleness of the upper extremities 
does not often show itself at first ; a hobble or limp is noticed, generally, 
at first, on one side of the body only. Other changes then take place, 
the upper extremities becoming involved, the face slightly distorted, the 
tongue is protruded with difficulty, and the speech thick ; these symp- 
toms, however, are often indistinct at first, with the exception of the fail- 
ure in the power of walking, which always shows itself The symptoms, 
for the most part, gradually but slowly advance, scarcely ever retro- 
grading. If the patient is insane, when the partial paralysis appears, the 
affection is nearly always fatal. Dr. Calmeil, who was connected with 
the lunatic hospital at Charenton, near Paris, considered it always fatal : 
and my own prognosis accords very nearly with his opinion. It is some- 
what singular that this disease is much more frequent in men than women ; 
although very common at the Bicetre and Charenton, it is comparatively 
rare at the Salpetriere, where none but women are admitted. 

In the diagnosis of this affection you must not, however, be too confi- 
dent; it is necessary that the cerebral symptoms should be permanent, and 
not merely limited to the slight disturbance of brain which occasionally 
results from disordered abdominal functions. If you are not quite sure. 
therefore, watch the patient for a little while, and the case will become 
clear. 

I shall not now enter at length into the pathological features of the af- 
fection, merely bringing before you two cases that came under my notice 
some time ago. One was of a gentleman, who died about two years 
since; he had been hurt by a fall, from the consequences of which he 
seemed to have recovered ; but two or three years subsequently his walk- 
ing began to fail, soon afterwards his mind, and a short time only passed 
after the development of these symptoms, before he died. On examina- 
tion after death we found the membranes of the brain universally thick- 
ened. The other case was that of a man, who had been a master of a 
vessel in the merchant-service; just previous to his attack, he had been 
suffering from a soreness of throat, which improved but little under a treat- 
ment consisting chiefly of local applications; symptoms of disease of the 
brain soon appeared, and the man entered the Pennsylvania Hospital. At 
44 



674 GERHARD'S CLINICAL LECTURES. 

this time he had incomplete paralysis of the lower extremities and of the 
left arm, with painful deglutition; these symptoms went on slowly, but 
finally destroyed the patient. After death, we detected a slight thicken- 
ing of the membranes lining the ventricles, and were astonished to find 
how little the medullary substance of the brain was affected, and that the 
cortical substance was merely in the normal state. 

Treatment in chronic meningitis is available only when the functions of 
motility are not impaired, and those of the intellect alone are affected. 
The mode of treatment to be resorted to, consists in a regulated diet, blis- 
ters to the nape of the neck and behind the ears, and cold affusions twice 
or thrice a-day. Although I cannot affirm that I have entirely cured 
any patients labouring under actual paralysis, I have certainly, by the 
plan detailed to you, restored several in whom the disease had proceeded 
no farther than the affection of the mind. The patient Urweiler is much 
better, speaks with greater ease, and has obviously more strength in the 
limbs. 

The next disease of the brain which I shall notice, offers, at this time, 
several cases in the wards of the hospital, and will be often encountered 
by you in the course of your practice — I mean apoplexy. <0f the cases in 
the hospital, one is a recent one, and two, in the black wards, occurred 
as far back as a year ago. The term apoplexy is often used very indefi- 
nitely. It is applied to four different pathological states: 1st, true apo- 
plexy, or hemorrhage into the substance of the brain or its membranes; 
2d, simple congestion, or preternatural fulness of the vessels of the brain; 
3d, serous apoplexy, in which the brain is oppressed and its functions im- 
peded by a large serous effusion ; 4th, nervous apoplexy, in which many 
of the symptoms, such as loss of consciousness, &c, are developed with- 
out any appreciable organic lesion. I shall here employ it to signify an 
actual hemorrhage into the substance or beneath the membranes of the 
brain, excluding mere effusions of serum^ all cases where there is no or- 
ganic lesion of the brain, as well as those in which mere congestion occurs, 
an affection which is most frequent during the summer season, and at the 
close of the winter. These cases are all confounded with true apoplexy, 
and indiscriminately classed under the same name; sometimes, indeed, 
when no one function of the brain is disordered, the term apoplexy is given 
to sudden deaths. A man will fall down dead, perhaps, with some coma- 
tose symptoms from disease of the heart, and his death is at once referred 
to apoplexy; whereas, genuine apoplexy almost never causes instantane- 
ous death. When the case terminates fatally, it is usually after a lapse of 
some months, from paralysis. It sometimes proves fatal in the course of 
a few minutes, or half an hour; but in these cases there is usually blood 
effused into the ventricles, and it is not common for it to terminate before 
the end of several hours, even when most severe. The exceptions to the 
rule, that sudden death does not follow apoplexy, are indeed so rare, that 
you may pretty safely pronounce an instantaneous death to be independent 
of this cause. These very sudden deaths are usually owing to diseases of 
the heart, although in some of them no organic lesion whatever can be 
found of any organ.* There was an example of this sudden death a few 
months since at the hospital, in a patient who was labouring under a chronic 
disease of the heart, who died during my visit. I found him in his ordi- 
nary condition, and had just left the ward, when I was suddenly called 
back and found him dead. 

* Memoir of Dr. Louis. 



APOPLEXY. 675 

The anatomical characters of apoplexy are easily ascertained, and may 
be divided into two great varieties — in the first and most common, the 
effusion of blood takes place into the substance of the brain, in the other 
it takes place into the membranes. Any spot in the brain may be the seat 
of the hemorrhage, but it is generally the thalamus of the optic nerves and 
the corpus striatum. The blood is sometimes poured out in such quantity 
as to break into the ventricles, and even force asunder the septum between 
them, so that it presses upon both hemispheres of the brain ; but it is gene- 
rally confined to a single spot, on one hemisphere. 

The character of the clot is always the same; it consists of a mass of 
dark coagulated blood, surrounded by the tissue of the brain, which is, to 
a certain extent, ecchymosed and softened: this softening may be either 
the effects of previous disease, or the consequence of the apoplexy. Dr. 
Rochoux, who observed at the Bicetre hospital, thinks that apoplexy al- 
ways depends upon the previous existence of local softening in the brain, 
the hemorrhage afterwards taking place in the diseased portion. My own, 
and the general opinion is, that in the large majority of cases, softening of 
the brain around the clot is a consequence of the pressure from the blood 
thrown out, the hemorrhage itself depending upon a disorder of the circu- 
lation. The cause of the deranged circulation is sometimes hypertrophy 
of the heart, which increases the impetus of the blood; at other times, the 
cause is to be sought for in a diseased state of the arteries and capillary 
vessels, either of the brain itself or of the whole system. But although 
the opinion of Dr. Rochoux is too exclusive, it is by no means unfounded, 
for there is a certain if not a larger proportion of cases, in which the evi- 
dence is decidedly in favour of previous lesion of the cerebral substance. 
These cases are somewhat analogous to the hemorrhage which follows dis- 
eased uterus, or the advanced stages of pulmonary tubercles. 

After the clot has been some time in contact with the substance of the 
brain, it is in a measure isolated by the formation of a cyst which com- 
pletely surrounds it. It is afterwards gradually absorbed, absorption 
taking place in the following order : first, the serum disappears ; secondly, 
the colouring matter ; and, thirdly, the fibrin of the blood. After a lapse 
of some months, the cyst only remains, in one of two conditions : — it is 
either entirely hollow, and lined with a new serous coat, or a little cel- 
lular substance occupies the old seat of the apoplexy, and then the cyst 
is either imperfect or entirely obliterated. In one of these two forms, the 
parts are invariably found. 

This succession of lesions has been perfectly well illustrated by the 
cases which have been just now under our notice, for there are particular 
symptoms, corresponding to each stage of the disorder. One was that of 
the old woman, in ward No. IV., in whom there was a complication also 
of softening of the brain. For, in addition to the paralysis which follows 
hemorrhage, we have strong contraction of the flexor muscles on the 
paralyzed side, so violent, that pain is given to the patient by an attempt 
to extend them. She had been well, we learned, two weeks before the 
attack, which determines it at once to have been of an acute character. 
The next point would be the manner in which it occurred, — was it sudden 
or gradual ? This we cannot settle satisfactorily, from our. inability to 
ascertain the previous history of the case. 

The paralysis might arise either from acute softening or apoplexv, and 
as the distinctive characters of these two affections chiefly depend upon 



676 GERHARD'S CLINICAL LECTURES. 

the abrupt commencement of the latter, and the more gradual progress of the 
former, it is evident that we cannot make a positive diagnosis. The 
rigidity which is so striking in the paralyzed side of the body, is pro- 
duced by softening, but this softening may be merely secondary to the 
hemorrhage. It does not take place in the beginning of apoplexy, it 
follows when the parts around the clot become inflamed ; whereas, in in- 
flammation of the brain, the numbness, stiffness, and rigidity follow in rapid 
succession, from the onset of the affection, and precede perfect paralysis. 
There is another fact showing the case to be apoplexy ; that is, the extent 
of the paralysis, which is rarely so great in inflammatory or non-inflam- 
matory softening of the brain. In acute and sub-acute meningitis, as I 
have before remarked, attacking the summit of the brain, you have deli- 
rium of a more or less violent character, the mind being always com- 
promised ; if it involve the base of the brain, you have alteration of the 
functions of motion, as subsultus, spasms, &c, and the sight is affected, 
but, as there is no paralysis at first, you cannot confound these diseases 
with apoplexy. 

Another point of some importance, in making a diagnosis of apoplexy, 
is to distinguish it, during the first few hours of the affection, from mere 
congestion of the brain. This is not so easy at first, as after the lapse of 
a few hours ; but there are some peculiarities about these affections, which, 
if closely attended to, will serve to draw the line of distinction. In the 
first place, after the first few minutes of the loss of consciousness, which 
usually occurs at the beginning of both, there is paralysis of one side 
alone, in true apoplexy. In congestion, on the other hand, there is 
scarcely ever complete paralysis of either, but there is generally some 
difficulty of motion in both. Persons attacked with apoplexy are not so 
commonly of the same full habit of body as those who suffer from active 
congestion, so that this plethora is alone sufficient to induce you to suspect 
the case to be congestion. A nice diagnosis, at the beginning of the two 
affections, is not very important ; it is only after they have advanced 
beyond the first stage, that it becomes of consequence, as regards the 
treatment, to distinguish between the two. For every case, offering the 
symptoms of loss of consciousness, difficult breathing, turgescence of the 
vessels of the face, &c, but one course of treatment is to be thought of, 
the actively depletory. But after the subsidence of these immediate symp- 
toms, cases which thus far offered the same character, demand a widely 
different plan of treatment. 

I have already alluded to cases of effusion of serum on the brain, which 
are sometimes confounded with apoplexy from hemorrhage, and, are 
termed serous apoplexy — a term often used to denote the presence of 
comatose symptoms, without hemorrhage. This serous apoplexy may 
occur from the effusion of serum beneath the membranes, or into the ven- 
tricles of the brain ; in the latter case, it is not unfrequent in mania a 
potu, and also in some diseases of a chronic character. These cases, 
however, of comatose symptoms from serous effusion are of rare occur- 
rence, except at the close of cerebral diseases of easy diagnosis. 

Sudden coma, entirely independent of organic disease of the brain, 
sometimes" appears, as the consequence of a previous chronic disease of 
various viscera, or even of anemia, under circumstances calculated not a 
little to puzzle the practitioner. A case of this sort occurred the winter 
before last, in my wards of the hospital. A seaman who had been ex- 



APOPLEXY. 677 

posed to great hardships, and had contracted a disease of the liver in the 
East Indies, of which he bore well-marked evidence in a pale-yellow, 
jaundiced skin, came into the ward complaining of neuralgic pains in the 
feet unattended with fever. He had no symptoms whatever of disorder 
of the brain, or of the thorax ; nor of the abdomen, except those indicative 
of a diseased liver. After remaining for a short time in the hospital, he 
was one night found with comatose symptoms, stertorous breathing, &c, 
having been seen, only an hour before, walking across the ward for a cup 
of water. I saw him only an hour before his dearth, in a state in which 
it was exceedingly difficult to arrive at a correct diagnosis; I, however, 
came to the conclusion that it was not apoplexy, from the fact of the 
symptoms not being limited to one side of the body. An examination 
after death revealed no alteration whatever of the brain, except a very 
trivial quantity of serum beneath the arachnoid. He had, therefore, coma, 
loss of consciousness, and stertorous breathing, during life, without any 
lesion of the brain. 

Symptoms of the same character occur from the effects of heat upon the 
nervous system, during the warm season. During the intensely hot weather 
of the summer of 1830, I witnessed the opening of the bodies of twenty 
or thirty persons who died from this cause ; we found no organic disease 
of the brain, but merely a slight congestion, such as is observed in other 
acute diseases, which it would be idle to set down as a cause of death. 
These were the appearances in those only who died suddenly of exposure 
to heat; for if time elapses for reaction to come on, inflammation of the 
brain may take place, but it is then a secondary affection. 

The other two cases of apoplexy, occurring in the hospital, to which I 
shall direct your notice, offer varieties of the disease different from the 
first described. They were black men, who entered the wards in a state 
of complete paralysis of one side of the body, one of them scarcely able 
to speak. He could articulate but the monosyllable ?io, which he an- 
swered to all questions whatever that were put to him. He seemed con- 
scious of the ridiculous nature of this invariable answer, but could not 
increase his vocabulary for several months, when he was gradually able 
to pronounce the shorter words, and now speaks very well, although there 
is still paralysis of one side of the body. In the other, the speech was 
merely thick, but his mind remained tolerably clear. They continued in 
this state for several weeks, and as the process of the absorption of the 
clot advanced, the intelligence brightened, but the paralysis remained. 
These were cases of hemiplegia, one side of the body being affected ; 
that opposite to the side of the brain, in which the hemorrhage occurred. 
This latter conclusion we drew from a law of pathology to that effect, 
which is almost without an exception in its operation. There may be one, 
two, or three abnormal cases out of a thousand, bur, in making your con- 
clusion, you may safely leave them out of the estimate. 

As the next consideration, in the study of the diagnosis, we had not 
only paralysis of the lower portion of the body, but also of the upper ex- 
tremity, and the muscles of the face, with disturbance of the intellect and 
senses, establishing, of course, the seat of disease to be the brain. The 
stiffness of the limbs was gradual in its progress, caused by inflammation 
around the clot ; but the paralysis was, at the time of the patient's en- 
trance, perfect; and the mouth was drawn towards the side which was 
not paralyzed, which is the reverse of what occurs in cerebral inflamma- 



678 GERHARD'S CLINICAL LECTURES. 

tion where the paralysis is active, that is, the mouth is drawn towards the 
palsied side. Our diagnosis and prognosis were at once made out ; there 
was a hemorrhage on one side of the brain, and it was incurable, because 
the paralysis was complete, in which cases it is for life, but when it is in- 
complete the patient may frequently recover. 

The liability of apoplexy to return is a matter of notoriety, and a point 
perfectly well understood in the world ; you should, therefore, in all cases 
where it has once occurred, be on the watch, looking for a recurrence of 
the hemorrhage, which nearly always takes place near the same spot, be- 
tween the thalamus and corpus striatum. 

The cases under notice were not fair specimens for testing the treat- 
ment proper for the paralysis of apoplexy ; but some of you may recollect 
a case, which "occurred last summer, of incomplete paralysis in a woman, 
which yielded entirely to treatment in a week. Dr. Foville of Rouen, 
explains the different success of the treatment in paralysis from hemorrhage 
by the occurrence in some cases of an actual rupture of the fibres of the 
brain, while in others these fibres are merely separated by the effused blood 
without being torn across. I am myself inclined to this opinion, and be- 
lieve that the medullary fibres are actually broken in most cases of com- 
plete hemiplegia. The routine of treatment in apoplexy is simple and 
familiar to all medical men. Very free bleeding is of course indispensable, 
in all patients, who are at all plethoric ; if of a pale, anemic complexion, 
it is to be practised with some reserve. Purging, foot-baths, and cupping 
are to be resorted to, although the latter is not of the same value here as 
in meningitis, where it is our sheet-anchor. I here indicate merely the 
general outline of treatment to be pursued in apoplexy, not entering into 
any details on the subject. In regard to depletion, I may remark that it 
is a point of some delicacy to determine how far to carry it. My rule is, 
to continue depleting until the circulation in the vessels of the head is 
lessened, which is to be ascertained as well from the appearance of the 
eye and countenance as from the pul^e. Purging I also push to some 
extent ; but you must be careful not to purge too violently, or that state 
of chronic softening of the mucous membrane of the intestinal canal, which 
w r as mentioned in a previous lecture as a frequent accompaniment of the 
exanthemata, may occur; it is a most unpleasant complication in paraly- 
tics, who rarely resist a diarrhoea long, however much they may have 
been previously benefited by purges. Blisters, setons, and issues, are all 
used in apoplexy, but with indifferent success, although the keeping up 
of a discharge by these means, is excessively useful in chronic meningitis. 
If, however, the apoplectic symptoms are pertinacious, these remedies may 
be tried once or twice, and continued according to the effect produced. 

If you are called to a patient suffering from apoplexy, after the full 
mischief of the hemorrhage is produced, and perfect paralysis is estab- 
lished, it is your duty to announce at once to the friends of the patient 
the impossibility of his ultimate recovery, explaining to them the nature 
and amount of organic lesions existing in the brain, and the impossibility 
of an entire cure. 

The last point in the treatment of apoplexy to which your attention 
must be directed, is the sores which are likely to occur about the sacrum, 
trochanters, &c, if the patient is obliged to keep his bed for any length 
of time. The bladder is also apt to become diseased in this affection, and 
you must watch and guard against too long a retention of the urine. 



ACUTE SOFTENING OF THE BRAIN. 679 

I shall conclude this lecture, by saying a very few words on the subject 
of acute or inflammatory softening of the brain. This affection is dis- 
tinguished from apoplexy, by the presence of fever, dizziness, and vertigo 
from the very beginning ; while you will rarely observe any febrile move- 
ment, in cerebral hemorrhage, till some time after the effusion of blood 
has taken place. The numbness of the limbs, which is a common symp- 
tom in softening of the brain, comes on very gradually, and, although the 
intellect is feeble from the first, yet the impairment of its faculties is com- 
paratively slow in its advance, there being at first, and for some time, 
merely dulness, and no active delirium afterwards. In a black man, 
under my care, four years ago, at the Pennsylvania Hospital, the delirium 
assumed the character of well-marked mania. This maniacal delirium is 
different from the more active kind occurring during the inflammation of 
the membranes and cortical substance of the brain. It is an affection 
which rarely occurs, except in the young and middle-aged, and is not to 
be classed with chronic softening of the brain, which is a sort of necrosis, 
or gangrene of this organ, and is met with only in old persons. In this 
latter disease, there is no active febrile movement whatever, the patient 
advancing, with unfailing certainty, from bad to worse, to death. The 
affection is dependent, according to Dr. Carswell, on a cartilaginous con- 
dition of the blood-vessels. Dr. Rostan, of the Salpetriere Hospital, ob- 
served the disease on a large scale, and has published a monograph upon 
the subject, in which he states it to be beyond the reach of treatment. 
In this country, I regret to say, that our experience does not materially 
differ from that of Dr. Rostan. 

The acute softening is, then, nothing but cerebritis or inflammation of 
the brain, while the chronic disease is almost the reverse of inflammation. 
As the latter affection is incurable, and occurs exclusively, or nearly so, 
in very old people, it is of little importance in a therapeutic point of view : 
but the acute softening may be cured in many cases if treated vigorously 
from the first. This treatment is similar to that recommended for menin- 
gitis, except that general depletion should be much more insisted upon ; 
local bleeding being of comparatively little value, at least in the early 
stages of the disease. The pain is often so slight in this disease as to lead 
the observer into an erroneous belief, that there is but little the matter 
with the patient, until either paralysis or decided mania supervenes. 
Hence a numbness of the side, if connected with disagreeable sensations 
in the head, or many signs of vascular congestion, ought to be treated 
with energy. 



LECTURE VIII. 

Apoplexy and inflammation of the brain (continued) — Functional diseases of the brain. 

I shall, this afternoon, again call your attention to some organic and 
functional diseases of the brain. It was my intention to have confined 
myself to the subject of functional cerebral diseases, but, owing to the 
termination of one of the cases of apoplexy, followed by acute softening 
of the brain, noticed in the lecture on these subjects, at the post-mortem 
examination of which some of you were present this morning, I am in- 



680 GERHARD'S CLINICAL LECTURES. 

duced to recur to the topic. The impossibility of understanding the sub- 
ject of organic diseases of the brain without a knowledge of their patho- 
logy, is well exemplified by the case under consideration, while, on the 
other hand, you have seen how exactly the phenomena after death coin- 
cided with what we were able, from the symptoms during life, to announce 
would be the case, and how entirely the prognosis as well as diagnosis 
has been confirmed by the result. 

This case was that of Fisher, one of the blacks alluded to in Lecture 
VII. He entered the hospital a short time after having been seized with 
loss of consciousness, and other symptoms denoting an attack of apoplexy. 
The inflammation, excited by the clot of blood thrown out, induced an 
inflammatory softening of the structure of the brain, which seems some- 
times to be a useful process, and promotes absorption of the clot ; it oc- 
curs from the same cause that gives rise to inflammations wherever a 
foreign substance is present in any portion of the body. The train of 
symptoms, announcing the existence of acute softening of the brain, we 
treated by cupping, purging, and a regulated diet, not using general 
bleeding from the enfeebled condition of the patient. Under this treat- 
ment, he was slowly getting better — he could crawl about the ward, and 
could articulate short sentences, when yesterday- he w T as seized with a fit 
of convulsions, as the nurse termed it, and was found by one of the resi- 
dent physicians in the state of coma, with dilated pupils, &c, which soon 
terminated in death. The examination after death, this morning, ex- 
plained the occurrence of these symptoms. 

We found, first, the remains of the old apoplexy, which had taken 
place a year ago, probably a few days before the man's admission, as 
nearly as we could gather from his imperfect account of himself. The 
disease had occurred at several different points of the left hemisphere of 
the brain. The left corpus striatum was shrunk and shrivelled up, and 
unnaturally hard and indurated. On incising it, at the depth of the eighth 
of an inch, a well-marked cyst was found, rather more than an inch 
long, and half an inch broad, lined with the usual serous membrane, which 
was not quite complete ; a part of the walls of the cyst were composed of 
loose cellular substance, filled with an opaque liquid. This serous mem- 
brane, lining the cavity, was not a true but an adventitious serous mem- 
brane, or rather sero-cellular, such as is thrown out in inflammation of 
the pleurae and pericardium. 

I have already told you, in a previous lecture, that these cysts are left 
after the complete absorption of the clot of blood. The evidence that they 
really arise from this cause is entirely complete ; it might, indeed, be 
inferred from the facts w 7 hich relate to the cases just pointed out ; but if 
you are not able to follow every step of the reasoning, I would refer you 
to the work of Dr. Rochoux. The cyst in question occupied one of the 
usual seats of cerebral hemorrhage. 

In addition to these morbid changes, there were the traces of a large 
apoplectic extravasation on the side of the brain, the conformation of 
which was obviously altered by a depression on the middle lobe of the 
left hemisphere, just behind the temporal muscle, quite unconnected with 
any alteration of the bone. 

The membranes adhered very closely to the substance of the brain, and 
beneath them was a partial softening of the medullary substance, which 
was of a light yellow or cream colour to the depth of about an inch, with 



APOPLEXY. 681 

complete destruction of the cortical substance in a space of two and a half 
or three inches square, that is, in the whole extent of the depression, 
necessarily rendering that portion of the brain totally unfit for use. At the 
posterior part of this softened portion was an imperfect cyst, more than an 
inch long, the walls of which were formed by a loose cellular substance, 
extending to the distance of from a quarter to a third of an inch. Near 
the centre of the same hemisphere, about an inch from the summit of the 
brain, was a third cyst, scarcely an inch long, of about half that breadth, 
and somewhat flattened. Its walls were formed by a hard and yellow 
medullary substance, and it was filled with a transparent liquid. One- 
fourth of the left hemisphere of the brain was, you thus see, destroyed ; 
it was, besides, distorted and drawn back, to a degree that f never before 
witnessed ; even the anterior portion of the brain was turned partially 
round and backward ; this distortion may have interfered not a little with 
the exercise of the functions of the brain, and was the necessary result of 
cicatrization after a complete loss of cerebral substance. 

From this disorganised condition of the brain, which rendered a large 
portion of it as useless as if it had been separated from the body, and 
caused the entire removal by absorption of another part, you may under- 
stand the cause of the complete paralysis of the right side of the body, and 
its necessary incurability, which I predicted. But in addition to the im- 
mediate consequences of the apoplexy, other changes had taken place in 
the brain, not necessarily the result of hemorrhage ; these were connected 
with the recent active inflammation, from which the patient peri>hed, as 
was shown by the softening around the old cyst. 

A symptom worth noticing was the loss of power of articulation, under 
which, you remember, the man laboured for a long period ; his answers 
were confined to the word no, and were afterwards brief and confused. 
Now there was no lesion, except that caused by the contraction, in the 
anterior part of the brain, which, of course, disproves Bouillaud's asser- 
tion, that the vocal powers are connected with this portion — a point which 
had, indeed, been previously satisfactorily settled by the observations of 
Andral and others. In this instance, the cortical substance of the brain 
was affected, although not in the anterior portion ; the cortical substance, 
I have no doubt, presides over the functions of the intelligence and of the 
voice. The corpus striatum is supposed to preside over the faculties of 
motion of the upper extremity; and here, you see, the patient regained 
the power of walking, though not that of moving his arm. This, however, 
proves nothing ; for it is a regular occurrence in hemiplegia following- 
apoplexy. 

The therapeutics of this case are important ; the impossibility of curing 
it is sufficiently evident, and consequently, the necessity of confining your 
efforts in similar cases to such a plan of treatment as will palliate and 
improve the symptoms. Hence too, you may doubt as to the propriety of 
addressing stimulating remedies to the brain and nervous system, as nux 
vomica, or its active principle strychnia, to relieve a paralysis dependent 
on destruction of the cerebral structure. These remedies were much in 
vogue at one of our institutions a few years ago, for the treatment of 
apoplectic hemiplegia. I witnessed most of the cases, and I never saw 
them produce decidedly good effects, although pushed so far, in some 
cases, as to produce convulsions. Many patients, afflicted with hemi- 
plegia, in a degree recovered ; but this occurred from the mere process 



682 GERHARD'S CLINICAL LECTURES. 

of absorption of the clot, and not from the effect of the remedy. Indeed, 
I must candidly express my opinion against the usefulness of the remedy ; 
and I am convinced that it often increases the activity of the circulation 
in the brain, surrounding the clot, from the over- stimulation of this organ. 
It is a valuable remedy in neuralgic paralysis, where there is functional 
disorder of the brain, or mere want of tone in the limb ; but when there 
is any considerable derangement of the cerebral structure, I am quite sure 
that it is often a hurtful medicine, even when given in minute doses, and 
suspended as soon as its effects appear. I make these remarks upon the 
strychnia, because its use seemed indicated in one of these cases of para- 
lysis ; and although I anticipated but little effect from it, I consented to 
its administration ; but it very soon became necessary to suspend it, from 
the increase of the difficulty of speech, and rigidity of the limbs. I am 
aware that many physicians of high judgment employ and recommend the 
strychnia ; but my own observations, which were the more unbiassed, as 
they were made upon the practice of others, and not upon my own, have 
led me to a different conclusion. The true therapeutics in paralysis from 
apoplexy, consist first in subduing the inflammatory symptoms or the active 
congestion of the brain, by blood-letting, appropriate applications to the 
head, and purging ; afterwards in waiting patiently and quietly, in keeping 
from the patient all causes of irritation, and in regulating his diet; and 
after the clot has been removed, in addressing gentle stimulation to the 
paralyzed part ; or what is better, in directing the patient to move it 
himself. Even this slight, and, as it were, natural mode of exciting the 
brain, may be attended with inconvenience. I lately directed a patient, 
in whom the paralysis was already of some months' standing, to move his 
arm every day by a powerful effort of will, and he went on until he suc- 
ceeded in raising his hand to his head, but the brain became excited, he 
was stupid, and his speech thicker, and I was compelled to make him 
desist. Avoid, then, all causes of excitement, whether medicinal or 
other, in these cases of paralysis, which are either the mere effect of a 
considerable rupture of the fibres of the brain, or are connected with the 
subsequent inflammation till very late in the treatment, and let it be con- 
fined to external stimulation. 

The case which we have just been noticing, illustrates extremely well 
the advantages of a knowledge of pathological anatomy, in the study of 
diagnosis. We were able to define with exactness the morbid condition 
of the brain, as you may see from the previous lecture, which corresponds 
precisely with that which a post-mortem examination has laid open. Now 
this verification, by means of examination after death of the lesions in a 
certain number of diseases, enables us to form a much more vivid and dis- 
tinct picture of the state of the analogous cases. We conceive, as it were, 
in our mind, a well-defined picture, and by a sort of second sight, can 
discover most of the changes, which are, under ordinary circumstances, 
completely concealed. If we gain but little direct assistance in therapeu- 
tics from pathological anatomy, we obtain a sort of touchstone, by which 
we judge of the power of remedies, and thus acquire more accurate notions 
of the effect of medicinal agents; we learn to discriminate between the 
natural course of a disease and the modifications impressed upon it by art. 
In itself, pathological anatomy is a mere instrument; but by its aid we are 
enabled to know positively a multitude of facts, which we can barely con- 
jecture from the unaided study of symptoms. Now, I would impress upon 



FUNCTIONAL DISORDERS OF THE BRAIN. 683 

you the necessity of not attaching an exaggerated importance to what is 
a mere means of investigation ; you must never isolate the lesions of an 
organ from the symptoms which accompany them. I am the more earnest 
in insisting upon this matter, because you might imagine, from the careful 
pathological investigations which I endeavour to make, that I value this 
sort of knowledge for its own sake; this would be an error in which I 
should be loath to fall. 

In concluding these lectures upon diseases of the brain, I have some 
few remarks to make upon certain functional affections of that organ, oc- 
curring during the course of various disorders of the body. These affec- 
tions are very numerous, and often not a little puzzling in their character. 
For example, you no doubt supposed, when listening to the detail of symp- 
toms denoting tubercular meningitis, that the features of the disease must 
be always clearly marked, and yet there are affections that sometimes simu- 
late it to a degree that will embarrass a very experienced observer. It is 
no easy matter always to distinguish between diseases of the brain itself, 
and those which are symptomatic of other affections. Now, this can only 
be done by becoming so familiar with these functional changes, that you 
may at once hold them up, as it were, in your mind's eye, and diagnosti- 
cate between them and the true cerebral diseases, by a rapid process of 
comparison, or as it is sometimes termed, by way of exclusion. That is, 
you run over the list of these analogous disorders, and then rapidly leave 
them out of your calculations, because some essential symptoms may be 
wanting. 

First, in fevers, intermittent and continued, particularly the latter, there 
occurs a train of cerebral symptoms which are placed amongst the most 
important symptoms of these disorders. Continued fevers, in this section 
of country, are almost wholly the typhus and typhoid fevers, with the ex- 
ception of the occasional occurrence of such as are styled bilious and ephe- 
meral, and are in themselves of little importance. In Paris, continued 
fever rarely takes any other type than the typhoid; while in Ireland and 
Great Britain, it is generally the typhus. In both these fevers, the brain 
is affected at the commencement, but in a less degree thnn in meningitis, 
the early symptoms of both being headache and dizziness, with loss of 
strength. In the second stage, there is stupor of great intensity in typhus 
and of slighter in typhoid, often running into delirium. We have, at this 
time also, in typhus, considerable disorder of the nervous system, indicated 
by spasms and subsulius, resembling those which occur in delirium tre- 
mens. The senses, also, are impaired in the second stage of both these 
affections, but more severely in typhus than in typhoid fever. In the last 
stage we have coma, complete loss of the powers of intelligence and of 
motion, and very nearly complete suspension of the senses. Sometimes 
we have violent, noisy delirium, which is to be looked upon as an irre- 
gular symptom, usually depending upon an accidental complication of me- 
ningitis with the fever ; when this violent delirium occurs, it is always to 
be considered and treated as a secondary meningitis. The ordinary mode- 
rate cerebral symptoms are, as it were, essential to the disease, and do 
not demand special interference, unless they should become intense, when 
they may be the immediate cause of death, and must then be treated as 
inflammations of the brain, by local depletion with cups and leeches, and 
by cold to the head, and the like. If this secondary meningitis of fever 
occur very hue in the disease, general bleeding is not often advisable. 



684 GERHARD'S CLINICAL LECTURES. 

Treatment, although useless in slight cerebral symptoms, becomes essen- 
tial when they reach a high degree of activity. After coma supervenes, 
it is proper to abandon a depletory course and the cold affusions, and you 
are now to resort to counter-irritants, sinapisms to the feet, blisters to the 
nucha, and to the temples or over the posterior part of the head — remedies 
which are improper during the violent stage of the secondary meningitis. 
In the partial epidemic of typhus which occurred last winter, the fever was 
attended with more active cerebral symptoms than had previously shown 
themselves. I used local treatment, in nearly every case, with extreme 
advantage, and found that, after removing the meningitis, the fever was 
almost free from danger. 

, In the intermittent and remittent fevers, the functions of the brain un- 
dergo alteration, although there is rarely active inflammation of the organ. 
There is less disturbance of the powers of motion than in typhus and ty- 
phoid fevers, subsultus seldom occurring. The senses are not affected, 
and except in the height of the paroxysm, there is little ringing in the 
ears. These symptoms, however,-are sometimes present in the malignant 
intermittents that we meet with in our hospitals, in the summer, occurring 
principally in sailors who have contracted the affection on the coast of 
North Carolina. In such cases, local depletion is not often "advisable, for 
the cerebral symptoms are not confined to the paroxysm, nor do they re- 
semble those of acute meningitis ; they are rather loss of memory, sighing, 
and other signs of enfeebled nervous energy. They are best managed by 
large doses of quinine during the interval, and during the paroxysm by 
wine and volatile alkali. Upon these symptoms the danger of malignant 
intermittents chiefly depends. Of coarse this mode of treatment is not 
designed for those cases in which there are signs of more active vascular 
excitement, requiring the treatment of the acute cerebral symptoms of 
typhus, or to cases in which the face presents a deep red or purple flush, 
as is the case in the apoplectic form of congestive disease. 

In pneumonia, there is usually some slight disturbance of the brain, 
which, indeed, accompanies, in a greater or less degree, all febrile affec- 
tions. Special treatment is required, only when there is either active 
delirium, or much stupor. When these exist, the case may be very rea- 
dily mistaken by one not well accustomed to recognise pneumonia. In 
the cerebral complications of pneumonia, the peculiar flush of the face, 
the dyspnoea, and dilatation of the nostrils, serve to distinguish the nature 
of the affection, while, if there be meningitis of a primary character, it 
will be marked by the brightness or injection of the eyes, frown of the 
forehead, and absence of the purple hue, and dark red flush. In the 
cerebral complication of pneumonia, a special treatment is occasionally 
demanded, consisting of purging, and antiphlogistics directed to the brain. 

In inflammations of the serous membranes of the thorax or abdomen, 
the brain is rarely implicated, except to a slight extent, corresponding 
with the vascular excitement. The same may be remarked of inflamma- 
tion of the mucous membranes ; in that of the bowels, the functions of 
the brain are not usually disordered, except in the last stage. If, how- 
ever, the mucous membrane of a large extent of the alimentary canal be 
simultaneously attacked, then the brain sympathizes, and delirium very 
commonly ensues. In very severe epidemics of malignant dysentery there 
is also extreme prostration of the nervous functions, somewhat similar to 
what occurs in intermittent fevers. 



DELIRIUM TREMENS. 685 

The connection between functional disorder of the brain and anemia, 
was alluded to in the la^ lecture, and illustrated very strikingly, by the 
history of a case which I then detailed. The sympathetic affection of the 
brain, in jaundice, is well known. We have a patient at this time, in 
the hospital, labouring under chronic gastritis and jaundice, in whom this 
cerebral alteration, depending on jaundice, is very manifest, and last year 
there were several marked cases of this kind. It is not, at least at first, 
of an inflammatory character ; the symptoms being merely stupor and 
prostration, with subsultus, and particularly, loss of the memory. This 
set of symptoms indicates the connection which exists between this affec- 
tion and malignant intermittent and remittent fevers, and in both it de- 
pends, in my opinion, upon the altered state of the blood which accom- 
panies hepatic disease. Treatment is to be confined almost entirely to 
sinapisms and blisters, and occasionally some slight stimulants in addition 
to the general treatment for jaundice — cupping or other depletion should 
be rarely used. But if the more settled and acute symptoms of meningitis 
supervene, the treatment must at once be antiphlogistic. Dr. Marsh, an 
Irish physician of eminence, has also called the attention of the profession 
to the cerebral symptoms of jaundice, and recognises their great danger. 
Anemia, dependent on a vitiated condition of the liver, is attended with 
many cerebral symptoms, sometimes these belong rather to the nervous 
system and spinal column than to the brain ; in other cases there are many 
signs of disturbed action of the brain itself. It is to be treated by tonics, 
iron, porter, and a generous diet. But in many disordered conditions of 
the cerebral functions, the proper remedies are to be found amongst the 
narcotics and antispasmodics. On the same principle is based the prac- 
tice, recommended by Dr. Graves, for the sleeplessness and slight delirium 
in the latter stages of typhous fever, consisting in a combination of opium 
and tartar emetic. This is an excellent remedy ; the antimonial slightly 
nauseates, promotes gentle perspiration, and predisposes to sleep. The 
virtues of Dover's powder depend on the combination of opium with an 
analogous medicine, ipecacuanha, and, if the alimentary canal be in an 
irritated condition, this combination is to be preferred. 

I have entered thus minutely into the detail of these functional cerebral 
symptoms, and into the points which distinguish them in different affec- 
tions, because the symptoms, which are laid down in books, are more or 
less analogous in all these affections. The order of symptoms, however, 
is very different, and diagnosis becomes comparatively easy if we attend 
to their successive development. 



LECTURE IX. 

Delirium tremens — Symptoms— Stages — Varieties — Complications — Treatment. 

Delirium tremens is an affection which has special claims upon your at- 
tention, from the lamentable frequency of its occurrence in our country. 
It is here, amongst the labouring classes, particularly the Irish,* one of the 

* The very happy reformation which has taken place among the Catholic Irish requires 
this statement to be modified. 



686 GERHARD'S CLINICAL LECTURES. 

most common of diseases, although in France and other continental coun- 
tries of Europe, it is comparatively rare. During my residence in Paris I 
did not see a single case of it: in the hospitals of that city it is a disease 
that is never thought of, in patients who enter with cerebral symptoms, 
although with us cases of delirium tremens are more numerous in our hos- 
pitals than those of all other cerebral diseases together. 

I now present a case of simple delirium tremens. The patient has been 
a drunkard from his twelfth year, and he is now upwards of forty; the fit 
of intoxication which gave rise to his present disorder commenced before 
Christmas, and continued until his entrance into the hospital a few days 
since. On looking at this man, the first thing that strikes your attention 
is a universal restlessness ; the whole body is affected with tremours ; when 
he holds out his hand, he is unable to keep it still ; his tongue, when pro- 
truded, is similarly agitated, but not to the same degree. Besides these 
tremours, last night, and several preceding nights, the patient was affected 
with hallucinations of mind ; these are still present, but are much less 
manifest than they have been. As I have stated in a previous lecture, 
fear is an almost constant characteristic of these hallucinations of delirium 
tremens ; but the fear is less of present, than of absent and imaginary ob- 
jects. From this fact we derive an important lesson in the treatment of 
this disorder ; that is, never to excite the fears of the patient, but to re- 
lieve them as far as possible by permitting him to have free intercourse 
with others; this will divert his mind from those terrifying objects which 
his imagination brings before him. The patient is always conscious of 
these hallucinations until his intelligence is entirely destroyed. They are 
most frequent and distressing when he is shut up in a cell ; in company 
they are much less so, and more under the control of his mind. 

In consideration of this subject, the important question occurs to us, 
what is mania a potu, or delirium tremens? It is not inflammation of the 
brain or its membranes; for the symptoms of these diseases are constant; 
there is a permanent disorder of intellect, and a lesion of muscular power 
throughout many parts of the body. In delirium tremens, on the contrary, 
there is no such constant and decided muscular disorder; there is no rigi- 
dity or paralysis, but only agitation and inability to keep still. Nor is 
there any positive defect of vision, or of the other senses, other than illu- 
sions or hallucinations; they are still perfectly retained, and entirely under 
the control of the patient. The condition of the intellect is likewise dif- 
ferent; in inflammation of the brain there are rarely hallucinations, pro- 
perly speaking, but" a more or less complete destruction of consciousness 
and aberration of intellectual power; in both these respects, we observe 
an opposite condition in delirium tremens. This marked difference in the 
symptoms is explained by a reference to the pathology of the two diseases. 
In inflammation, there is injection of the membranes or substance of the 
brain, with thickening of the former, and various other organic lesions. 
In delirium tremens there is no organic change ; the only abnormal ap- 
pearance which can be detected, is an effusion of serum into the ventri- 
cles of the brain, and a preternatural moisture of the cerebral substance. 
This superabundance of fluid arises from the continued irritation to which 
the brain is subject, and the slowness with which it occurs ; it is not the 
cause of the symptoms; they are produced by the irritation, which, after 
it has continued for a longer or shorter period, gives rise to the effusion. 
The two diseases also differ in their progress. Mania a potu, like mea- 






DELIRIUM TREMENS. 687 

sles, scarlatina, &c, has a definite course and a natural termination ; it 
must disappear after a certain time, unless the attack be a very severe one. 
No treatment is of any further use in the mild cases than to diminish the 
inconveniences of the disorder ; any treatment which is not directed to this 
simple end, proves injurious by irritating and harassing the patient. 

Delirium tremens begins in two different ways. The most common is 
that in which from some cause, as accident, disease, or resolution of the 
patient, or inability to obtain intoxicating drinks, the patient suddenly gives 
up his accustomed stimulus. This is the most simple variety, and under 
ordinary circumstances, after a period of restlessness of two to three days, 
passes through a natural crisis, consisting in a prolonged sleep of some 
hours, and terminates in recovery. If no untoward circumstances occur, 
the sleep will follow of itself, and the disease is therefore strictly a self- 
limited one ; treatment merely assuaging the suffering of the patient and 
diminishing the mortality. The second mode of invasion is that in which 
the delirium tremens is most apt to be complicated with inflammation or 
congestion of the brain or stomach, or with convulsions. The patient con- 
tinues to drink freely until his attack, but the stimulant is taken irregularly, 
or acts irregularly, strongly exciting the brain at one moment, and then 
leaving the patient in a state of depression. The circulation is often much 
excited, and the face flushed, and the eyes injected. These cases are apt 
to be attended with convulsions of a mixed form, sometimes resulting in 
apoplexy, at others epilepsy. These convulsions sometimes, though rarely, 
occur immediately on a debauch, more frequently, however, they take 
place in patients who are in a state of vascular as well as nervous excite- 
ment from intemperance, and suddenly abandon all stimulants. The con- 
vulsions, and indeed this variety of the disease, are not so frequent in the 
poor as in those who, with more means of gratifying their vicious desires, 
are sunk into greater debauchery. The hallucinations and other disturb- 
ances of the intelligence are less marked in this variety than in the ordi- 
nary form. We may state this by saying, that the vascular and nervous 
symptoms are more developed, but the intellectual less so. 

For the study of ordinary delirium tremens, it is convenient to divide 
the disease into three stages : — 

(a) First Stage. This is well known amongst drunkards as the horrors: 
a term which expresses the aspect of the patient, which is that of extreme 
anxiety and agitation, and the distressing feelings of fear which the patient 
experiences. The anxious alarming expression is one of the most cha- 
racteristic symptoms of the disease, and with the tremour, which is equally 
remarkable, it constitutes the only pathognomonic character. The tremour 
extends to the whole muscular system, but as it may be to a certain ex- 
tent restrained by a voluntary effort of the will, or by supporting the 
weaker muscles of the limbs against the trunk, it is sometimes not very 
obvious unless the patient is directed to put out his tongue, or to hold up 
his hands, where it is at once perceived. The restlessness and tremour 
are the most frequent and important symptoms of the first stage of the dis- 
order, but are by no means the only ones ; the others, how T ever, are only 
accessory or secondary, and vary with each patient. As a general rule, 
the pulse is feeble and frequent, the mind is unable to direct itself long to 
any single subject, and the pupils are slightly contracted. The complex- 
ion is extremely variable ; it is often pale if the patient has not been long 
addicted to intemperance, but, in the majority of cases, it retains the usual 



688 GERHARD-S CLINICAL LECTURES. 

tint of the drunkard's countenance. The appetite fails, the bowels are 
often constipated, and there is generally more or less thirst. In this stage 
of the complaint the restlessness continues throughout the night, and of 
course the patient is unable to sleep : sometimes, the sleeplessness is the 
first symptom of the disease, but in the majority of cases it attends the 
restlessness, and is strictly proportioned to it. The agitation may gradu- 
ally subside and the patient recover, or the disease may pass into the next 
stage. 

(6) The second stage of the complaint presents the same symptoms as 
the first, but in an exaggerated degree, the tremours, .restlessness, and in- 
somnia are increased, and the appetite is more completely destroyed. 
The pupils are more contracted ; if, however, the patient has not taken 
opium, the contraction of the pupils is never very great. The distinctive 
symptom of the second stage, is the illusions which at first occur only at 
night, when the patient is left alone, and in the dark. These halluci- 
nations are perfectly under the control of the understanding when the 
courage of the patient is revived by light and society : he is then perfectly 
aware of their nature, and will often laugh at his own fancies. The illu- 
sions are not confined to the night, if this stage become more confirmed, 
but they still remain perfectly under the control of the willand of the in- 
telligence ; if the disease continue, the illusions become more and more 
frequent, and cease to be recognised by the patient, that is, they are com- 
pletely confounded with real objects. The attention may still be directed 
to surrounding objects, and the patient is capable of answering ordinary 
questions with perfect correctness, if he is addressed in a sharp, decided 
tone of voice, and there is no incoherence in his answers, so long as his 
attention can be commanded. These illusions are nearly always of an 
alarming kind, and are as varied in their nature as the objects which hap- 
pen to be most familiar to the patients ; devils, guns, fire, serpents, and 
the like, are the most common objects of his fear. At other times he feels 
a vague dread that his life will be taken, and earnestly entreats that it 
may be spared. These illusions are so well characterized, that they have 
always been regarded as the essential character of true delirium tremens ; 
this is nearly but not absolutely correct, for, in some cases, the tremours 
are not attended with illusions, but on the contrary, the mind of the pa- 
tient is almost clear, and the disease may prove fatal, although no illusions 
present themselves, by the occurrence of convulsions or sudden insensi- 
bility. Still, in the regular simple variety, of which I am now treating, 
the illusions may be regarded as a constant symptom. The other symp- 
toms of the second stage are not pathognomonic, and with the exception 
of the countenance, which retains the same restless expression as in the 
first stage, are not even characteristic. The pulse is frequent, and gene- 
rally small, the frequency evidently depending rather upon the extreme 
agitation of the patient than any regular connection between the state of 
the circulation and the disease. The appetite rarely returns during this 
stage, although this is sometimes the case ; the tongue is generally furred, 
but rarely dry. The skin remains moist throughout this stage, and if the 
efforts of the patient to escape from confinement be constant, or if his agi- 
tation be very great, the sweat is often very profuse. This sweat is of a 
different character from that which generally occurs during the third stage 
of the disorder, and seems to be strictly dependent upon the constant ex- 
ercise which the agitation of the patient obliges him to take. The second 



DELIRIUM TREMENS. 689 

stage may gradually decline, and the patient fall asleep, and recover ; or 
it may pass into the next stage. Sleep is nothing but the indication of 
the recovery ; it follows rather than precedes the decline of symptoms. 
The insomnia arises from the extreme nervous disturbance which is the 
essential element of the disease, and although the fatigue of the patient 
may be extreme, he is still altogether unable to sleep. Let the nervous 
agitation be quieted by any means, and sleep will immediately follow, 
and will finally complete the restoration. This is the true rationale of 
the close connection between sleep and recovery, which has certainly 
been misunderstood, and has led to erroneous deductions as to the treat- 
ment of the disease. If the disease be completely removed, the patient 
will sleep for a long time, and will generally awake perfectly restored. 
In some cases, however, the recovery after prolonged sleep is not com- 
plete, but the disease recurs again, and is not completely cured until a 
day or two afterwards. If the prolonged sleep occur naturally, it is always 
productive of great relief to the patient, but if it be forced by the opera- 
tion of narcotics in large doses, instead of conducing to recovery, it will 
sometimes end fatally, and the patient may then die without awaking. A 
short sleep of one, two, or three hours is refreshing, but is not usually fol- 
lowed by immediate recovery, although it affords an evidence of the gra- 
dual decline of the disease. If delirium tremens be well treated, or if the 
disease be essentially mild, but few cases pass beyond the second stage ; 
recovery taking place without difficulty. 

(c) The third stage is attended, like the others, with a symptom which 
is characteristic ; that is, incoherence. The illusions either cease, or they 
are no longer connected, — the patient passing from one object to the other 
with great rapidity, and not reasoning correctly or connectedly upon the 
images which are presented to his mind. He becomes feeble, but is, at 
the same time, extremely agitated, and can only be retained in bed by 
the constant watchfulness of an attendant, or by straps or bandages. The 
sweat becomes profuse, the skin sometimes cold, at others warm, and 
pupils greatly contracted. The contraction sometimes ceases before death, 
and may be succeeded by a morbid dilatation, if there be much serous 
effusion upon the brain. The senses become gradually more and more 
obtuse, from the first appearance of incoherence ; the patient generally 
loses his power of attention, and can with great difficulty be induced to 
direct his attention to surrounding objects, and as the disease advances, 
he becomes completely comatose, and generally lies in a state of insensi- 
bility for some time before death. The pulse gradually fails during this 
period, and the patient often presents symptoms of nervous disturbance, 
which are very analogous to those which take place in cases of typhus 
fever, such as subsultus, spasmodic tremours of the muscles generally, and 
muttering delirium. 

Emetics have frequently been employed for the cure of this disorder. 
They act by producing relaxation and diaphoresis, and in some cases this 
practice succeeds very well. But in other cases (especially in that sort 
which is not unfrequently met with in private practice, where the disorder 
is brought on, not by a fit of intoxication, but by a long course of free 
drinking), emetics may do a great deal of harm ; instead of tranquillizing 
the system, they sometimes produce a great deal of prostration, which, 
in some cases that I have seen, has undoubtedly been the cause of death. 
Tartar emetic is particularly liable to this objection. 
45 



690 GERHARD'S CLINICAL LECTURES. 

Of the various other remedies employed in the treatment of delirium 
tremens, opiates have probably received most attention. I formerly used 
these remedies in almost every case, though not in as large doses as some 
of my brethren ; but when I was a resident physician in this hospital, we 
were directed to give opium in very large doses, — frequently as much as 
four grains every two or three hours, until sleep was procured. The pa- 
tients, for the most part, got well under this treatment ; but in estimating 
the value of a particular plan of treatment, we ought to consider the pro- 
portional success of this and other plans. A comparison of this sort will 
prove that opium is not the most effective remedy in mania a potu. In 
conjunction with this remedy certain hygienic regulations were also en- 
forced at the time to which I have alluded. The patients were locked 
up in cells, and if very disorderly, that is in every severe case, they were 
confined in a strait jacket, or tied in bed, with gloves and straps. 

The practice of the hospital has never been to give opium to the exclu- 
sion of other remedies ; it was always the custom to use cups and cold 
applications to the head, purgatives and various other remedies, when they 
seemed necessary. From time to time a change would be made in the 
practice, and the affection would either be treated upon empirical grounds, 
in accordance with the varying symptoms, or the emetic practice would 
be pursued. 

But the plan of treatment, by opiates and confinement, is the one that 
was almost universally practised in Philadelphia several years ago, with 
variable results. In my own practice I have gradually diminished the 
quantity of opium which I formerly gave, and for some time past have not 
used it at all. Instead of it, I have relied in bad cases upon the 
stimulant treatment which had been always followed in some plans ; that 
is, the use of stimulating remedies, particularly alcoholic liquors. These 
articles I first employed in conjunction with opium, or prescribed them 
without opiates, in two different conditions: 1st, in the slighter cases, or 
those of incipient delirium tremens ; or 2dly, in the severe cases where 
opium had been employed but was followed by distress of mind and stupor. 
But at present I use them singly. This treatment has diminished the 
mortality of the disease. The change which I have adopted in the hy- 
gienic rules has also contributed very decidedly to this result. Instead 
of confining the patients, I let them walk about and enjoy the company 
of others as much as they choose : merely taking care that some one 
should be near them to prevent accidents. I was led to this change 
by observing that the hallucinations which attend the disorder were more 
distressing when the patients were in a state of confinement than when 
they were allowed to walk about as much as they wished. As I have 
already remarked, they are capable of controlling these hallucinations, 
until the intellect is entirely destroyed ; and they can do so the more 
easily when they are surrounded by ohjects which serve to engage their 
attention. Confinement always irritates them, and increases their ravings, 
so that the third stage, in which the intellect is entirely destroyed, is apt 
to be brought on very speedily. I have very often tested this by a simple 
experiment; a man who was confined to his bed by a strait jacket, or 
something of the kind, I have frequently directed to be dressed, have 
soothed him by conversation, and after requiring a promise that he would 
conduct himself with propriety, I have very seldom found reason to be 
dissatisfied with the result. On the contrary, the disease would almost 



DELIRIUM TREMENS. 691 

invariably become milder, and the necessity of confinement cease. It is 
true that confinement is often necessary at night, from the impossibility of 
always providing a sufficient number of attendants. I therefore (with the 
exception just stated) allow the patient to have full liberty, the only 
restraint being the presence of the keeper: sometimes, also, [ direct them 
to be set at w T ork, which serves still farther to distract their attention. 

The proportional mortality under the two plans of treatment which I 
have detailed, is represented in the following summary, comprising the 
number of cases treated amongst the men for the space of 5J years — that 
is, from the 20th of May, 1834, to the 13th of November, 1839. The 
whole number of cases admitted for delirium tremens, or intemperance 
which was expected to terminate in delirium tremens, was 1241. Of 
these, there were 1198 whites, and only 43 men of colour. Of the whole 
number, 708 were decided cases of delirium tremens, 60 were slight 
cases, and 430 cases of mere intemperance. Of the latter, some termi- 
nated in decided delirium tremens, and others proved fatal from diseases 
(such as pneumonia) contracted during the fit of drunkenness, for which 
they had been sent to the lunatic asylum. So that this class furnishes a 
considerable number of bad cases. Of the whole number 121 cases 
proved fatal. That is, a fraction less than one in ten. 

In the first year, from May, 1834, to the same date, 1835, the number 
of admissions was 141 ; of these, 18 died : that is, rather more than one 
in eight. In the second year, the number of cases was 211, the deaths 
24, or a little more than one in nine. The third year, in 301 cases there 
were 47 deaths, a much larger proportion than in preceding years, one in 
6^f, but depending upon an accidental cause, that is, the coincidence of 
an epidemic of typhus, which attacked many of the debauched subjects 
of intemperance: some of them were sent to the lunatic asylum as labour- 
ing merely under the effects of intemperance, and could not be afterwards 
removed to the proper ward. 

In the fourth year, beginning May, 1837, of 206 cases, 19 only proved 
fatal, that is, about one in eleven. This was a decided amelioration, and 
coincides precisely with the epoch at which the change of practice was 
introduced. 

In the fifth year the mortality went on diminishing, and was less than 
one in twenty-six ; or of 274 cases, 9 only were fatal ; and amongst 
these cases, the mortality was certainly greatest in those which were 
treated chiefly according to the method formerly pursued at the hospital. 

Finally, in the six months, ending November, 1839, the mortality was 
only one in 33 j- , that is, 4 cases out of 135 ; and of these four, one 
entered moribund, and was not, therefore, treated in the hospital ; ano- 
ther had inflicted upon himself several fractures and other injuries, by 
leaping from a. third story window, in a fit of delirium tremens, pre- 
viously to his entrance. The others, it is believed, were also complicated 
cases. 

The preceding summary of the results of the treatment, is extracted 
from a lecture which I delivered at the Philadelphia Hospital, in Decem- 
ber, 1839. The results of the treatment for the last year, up to October, 
1840, have been still more satisfactory. The number of cases of the 
sequelae of intoxication, and of delirium tremens in the three stages, ad- 
mitted into the men's wards of the Philadelphia Hospital, from October 
12, 1839, to October 12, 1840, is 223. Of these, 61 were classed under 



692 GERHARD'S CLINICAL LECTURES. 

the head of intoxication, or its immediate sequela?, some of them passing 
into delirium tremens. If we exclude the whole of these 61 cases, there 
remain 162 cases of decided delirium tremens ; of these, 87 were admitted 
in the first stage, 73 in the second, and 2 in the third : 160 cases reco- 
vered, and one remained convalescent, who is since well (Oct. 16). One 
only proved fatal : this patient was admitted in the third stage of the 
disease, and died in a few hours after his entrance ; he had been treated 
with opium, and a box of pills, which he was taking, was sent to the hos- 
pital with him. Of course, this apparent exception confirms the general 
conclusion, that the disease terminates favourably in every instance, when 
treated according to the method recommended. 

Up to the present date, August, 1841, from November, 1840, the mor- 
tality, including complicated and moribund cases, has been about one 
per cent. That is, in no case in which the stimulant practice was thought 
necessary did it fail, except in those in which, from the late admission of 
the patient, or some other accidental cause, it was not fairly tried ; and 
counting all such, the ratio still remains insignificant ; while the opiate 
practice yielded a large mortality under the same circumstances. I do 
not, however, think it necessary to resort to alcoholic stimulants in slight 
cases ; and still less in the slight gastric nervous disorder which follows 
simple intemperance, but does not amount to delirium tremens ; some- 
times it is better to avoid them carefully under these circumstances. 

The plan of treatment which I have found to answer best, is as fol- 
lows : — 

If a patient come under your care partially intoxicated, but still labour- 
ing under some of the premonitory signs of delirium tremens, give him 
an emetic of ipecacuanha : he will in general be disposed to sleep after 
its operation ; when he awakes, or soon after taking the medicine, if he 
does not sleep, he will complain of gastric uneasiness, and often of slight 
nervous symptoms. Fresh air, exercise, and a strong infusion of gentian, 
or some other bitter, with capsicum or ginger, will then do much to allay 
the irritability of the stomach and diminish his discomfort. Alcoholic 
stimulants are not necessary in such cases ; and these simple remedies 
constitute my usual treatment. 

If the disease promise to become more protracted, a mixture of lac 
assaftfitidae, with tincture of valerian (ammoniated) and Hoffman's ano- 
dyne (3SS. of each of the latter remedies with giij; of lac assafoetida every 
two hours) are of great benefit in tranquillizing the patient. As a drink, 
he may take a bitter infusion with an aromatic. These remedies, with 
exercise, and as nutritious a diet as the stomach of the patient will bear, 
are sufficient to remove the symptoms if they are slight. 

If the disease become more decided, and pass to hallucinations, espe- 
cially if these are not recognised as such by the patient, the stimulant 
practice may be resorted to. The severity of the disease from the first is, 
however, a better guide than the mere occurrence of hallucinations. 
Thus, if the disease be very violent, even before any hallucination can 
be detected, the patient may take alcoholic stimulants; but it is especially 
in those cases in which both tremours and hallucinations are present that 
the stimulant practice is applicable. The same treatment is indicated 
when the patient is threatened with convulsions ; but if the face be 
flushed, and more or less livid, the cold affusion, or the simple application 
of ice to the head, should be conjoined with the stimulants. 



DELIRIUM TREMENS. 693 

Various alcoholic preparations will answer the same end. Whiskey 
with quassia is by no means palatable, and at the same time suits well 
with many drunkards, but some of them are nauseated by it and require 
brandy, gin, or the like. The dose is necessarily very various : on no 
account, and under no circumstances, is it either necessary or proper to 
give a sufficient quantity to render intoxication possible. Our object is 
the very reverse of this : it is simply to tranquillize the agitation of the 
nerves by small doses of a poison to which the patient has been accus- 
tomed, but not toxicological doses ; and these small doses may seem large 
in some patients, although they are in reality small compared with their 
habitual allowance. For most purposes, one ounce of the above-men- 
tioned stimulants may be given every three or four hours ; in bad cases, 
two ounces may be given every two hours, for a few doses, and then in 
a less dose. In very few cases was this quantity exceeded, and then only 
for a very short period, when the life of the patient appeared dependent 
upon the prompt revival of his sinking powers. If the patient be feeble, 
the stimulant may be given in the form of milk-punch, or in arrow-root. 
The largest dose is generally required for a single day, afterwards it 
should be gradually lessened, and after a sound sleep, or as soon as there 
is a decided diminution of the tremours, all alcoholic remedies maybe 
given up and supplied by a simple bitter infusion, or the assafoetida mix- 
ture. In some cases the cure takes place, as it were, abruptly, and the 
patient is at once restored to health ; in others, after the cessation of vio- 
lent symptoms, the patient may remain in a nervous state with some tre- 
mours, but no decided hallucinations : there is at the same time in many 
cases some indications of active excitement of the brain. This state of 
things is, however, much less frequent after the alcoholic than the opiate 
practice ; but in either case, the best remedies are a smart purgative, 
exercise in the fresh air, and cold affusions on the head. 

There are often complications which require some modifications of the 
treatment, but they are less frequent than in the opiate practice. The 
most common is gastritis ; to a greater or less extent it may be said to be 
natural with drunkards, and ceases in a great degree as soon as the cause 
is removed ; if it be not very intense, it requires no special treatment. 
This slight gastritis is often attended with vomiting, which ceases after 
an emetic, or the administration of the usual stimulants. If, however, 
the disease be severe, with red tongue, and great tenderness, and constant 
vomiting, all stimulants should for a time be suspended, or they may be 
given in small quantities and iced. Bladders, or cloths, containing ice, 
may be applied to the epigastrium, the proper diet for gastritis directed, 
and cups and leeches may be used if the former remedies prove insuffi- 
cient. When the gastritis becomes very intense, the symptoms of delirium 
tremens in general subside, and seem displaced by it ; and the brain 
symptoms become then secondary to gastritis, such as fixed but muttering 
delirium. These are often confounded with those proper to delirium 
tremens. Congestion or inflammation of the brain may complicate, 
replace, or succeed to delirium tremens: when they appear as mere com- 
plications they may often be relieved by the means I have indicated 
without suspending the treatment proper to the disease. But if the vas- 
cular disturbance of the brain constitutes the disease, and the delirium 
tremens is either not developed or disappears, the treatment becomes that 
which is adapted to the particular cerebral state, and venesection is some- 



694 GERHARD'S CLINICAL LECTURES. 

times under these circumstances of immense value ; but, as a general rule, 
local bleeding, revulsives, and refrigerant applications, are better means 
of restoring the balance of the system. These vascular affections of the 
brain are always produced in some individuals after a debauch, or even 
moderate indulgence ; in a few they may occur upon taking a single glass 
of wine. Of course, in the latter case they are dependent upon a peculiar 
idiosyncrasy, in which a very small dose of an alcoholic stimulant acts as 
a virulent poison. If the vascular excitement of the brain from a debauch 
be not attended with the symptoms of real delirium tremens, or if they be 
very slight, and be concealed as it were beneath those of excitement, 
then it is very clear that the case should not be treated as one of de- 
lirium tremens ; — an error of diagnosis in this respect would be mis- 
chievous. 

In pointing out to you a mode of treatment which a long experience 
has shown to be safe and remarkably certain in its results, I am very far 
from excluding other means as injurious ; on the contrary, many of them 
may be used in connection with the stimulant practice, or may be substi- 
tuted for it, if you have strong objections to this mode of treatment. 
Should you prefer opium, I would warn you against giving it in very 
large doses, except you can observe the condition of your patient before 
administering each of them. By combining opium with tartar emetic or 
ipecacuanha, you may succeed in producing calm or sleep in smaller 
doses than if given alone. Although it was the remedy formerly relied 
upon in the hospital, I have not administered it for two years, except in 
rare cases for some intercurrent disease, such as dysentery. In some in- 
stances, as of fractures of limbs, &c, it may be necessary to use opium, 
but these are rare: there is another case in which it may be of service, 
that is, when the patient is tranquil, but still sleeps little ; a moderate dose 
of opium is then at times of service. 

In recommending to you a practice of this kind, I do so simply because 
I believe it to be a duty to inform you of the results of my experience in 
the treatment of this disorder. The great success of the treatment is a 
matter of demonstration ; while there can be no possible objection to the 
practice, except the fear of giving something like a sanction to the asser- 
tions occasionally made by drunkards, that they cannot do without their 
stimulants. This, however, is clearly an error: the continued use of 
alcoholic liquors even as a remedy is always injurious and reprehensible ; 
but this is very different from their employment during the two or three 
days of an attack of delirium tremens. 

The examination of the records of the hospital do not show that the 
admissions for delirium tremens of the same individuals are at all influ- 
enced by the treatment in previous attacks, whatever that may have been ; 
on the contrary, there is strong reason for believing that such is not the 
case. The thirst for alcoholic drinks, once acquired, can only be over- 
come by a moral action and a strong will on the part of the patient ; hence, 
it is extremely rare to find a drunkard reformed from fear of illness or 
suffering. The will to abstain, for it requires an act of strong volition, 
must come from other reasons ; and the influence of the societies which 
are now labouring in the reformation of the "intemperate, is certainly en- 
hanced by the support which they receive from mutual encouragement 
giving strength to the feeble will of the intemperate. 

After a treatment, or after an attack without treatment, of delirium tre- 



DYSENTERY. 695 

mens, the patient should break up his old habits of association of time 
and place, take a journey, engage in some new and active employment. 
Shower-baths, or simple cold baths, with some light purgatives, are use- 
ful in dissipating the remains of the disease, and in favouring sleep when 
the disease is no longer in its most active stage, but is not entirely re- 
moved/ 



LECTURE X. 

Dysentery — Varieties — Diagnosis — Anatomical lesions — Treatment. 

Dysentery is a disease of unfrequent occurrence in the cold seasons of 
the year. It is most commonly met with in summer and fall, the liability 
of inflammation being transferred with the approach to winter, from the 
bowels to the lungs. I, however, present two cases of dysentery, one of 
the acute, the other of the subacute form. 

The latter is that of a man aged sixty-five years ; he has generally en- 
joyed good health : on his first admission into the hospital, he had inter- 
mittent fever, from which he recovered, and went about his usual em- 
ployment. About a fortnight after this (on the 1st of October), he was 
again admitted, having been seized with dysentery two days before. It 
came on with frequent discharges from the bowels, which were watery, 
and passed with little pain. In a few days the character of the stools 
changed ; they became yellowish, and were composed of thin fecal mat- 
ter, mixed with mucus; but there was no blood. The patient has also 
suffered pains, but of no great severity, along the course of the colon, 
from the caecum to the sigmoid flexure. He has not experienced nausea ; 
his appetite has been tolerable ; he has suffered little from thirst. The 
skin has been harsh and dry, with considerable emaciation, and a coun- 
tenance indicative of griping pain in the bowels ; the features which give 
to it this expression, are the frown on the brow and compression of the 
lips. The degree of emaciation has varied frequently with the intensity 
of the case ; being on one day extreme, — the next much diminished. 
The pulse has been sometimes quick, sometimes slow ; it now beats 96 
in the minute. The skin is cool ; there is, therefore, very little fever, 
nor has there been much at any time in the course of the disease. The 
tongue has been, throughout, dry, cracked, and red, as it almost always 
is in severe cases of chronic dysentery. This appearance of the tongue is 
not so frequent in acute dysentery, because the inflammation requires some 

* Since the time at which this lecture was delivered, I have seen no reason for making an 
important change in the opinions I had at that time formed from a very extended observation 
of delirium tremens. 1 still rely mainly on the alcoholic remedies in cases of the disease, and 
believe that they, either alone or given in conjunction with some other stimulant, constitute the 
surest means of bringing the disease to an early resolution. I do not, however, object so 
strongly to the use of opium in private practice as in hospitals. It there seems to be oftener a 
matter of necessity to give opiates than it is in the wards or cells of a hospital, where provision 
is made for the convenient treatment of patients labouring under delirium tremens. In hos- 
pitals even, the use of opium ought not to be neglected ; it is often a valuable adjunct to the other 
remedies for the disease, and may be given with safety, provided it be not administered useless- 
ly or without inquiring carefully into the condition of the patient. But it is certainly not on 
the whole the best or safest remedy for the treatment of cases of delirium tremens. It ought 
to be used as a useful assistant to the other means of treatment, and not to be regarded as the 
only agent capable of quieting the nervous disturbance, which constitutes the main feature of 
the disease. June, 1848. 



696 GERHARD'S CLINICAL LECTURES. 

time to extend itself up the alimentary canal. In chronic cases we often 
find this condition of the tongue attended with a disagreeable taste, and 
even ulcers in the mouth. The patient's tongue is now become natural ; 
abdomen slightly tender, and not retracted. 

The acute case is that of a woman, forty years of age. She was admit- 
ted on the 12th of November. During the summer, she had an attack of 
dysentery, and has since been confined in the wards with rheumatism, 
but had recovered. Her present illness commenced on the 10th inst. 
The discharges were frequent and watery ; on the 12th they contained 
mucus with some blood. She has had fever, but no chills ; nausea, but 
no vomiting. 

15th. The countenance is anxious ; abdomen extremely tender and pain- 
ful ; stools passed every hour; they contain mucus, but no blood. 

To-day (16th) the blood has reappeared in the stools. This disappear- 
ance and reappearance of blood in the stools are of frequent occurrence in 
acute dysentery. The history of the case shows that the stomach has re- 
mained nearly intact, the disease being confined to the large intestine. 

Present condition of 'the patient . — The countenance is very slightly flushed, 
especially the lips ; there is no compression of the lips, as in the former 
case ; the countenance expresses nausea and disgust, rather than griping 
pain. The skin is moist and pleasant, but has been warm and more dry. 
The tongue is covered with a brownish fur, but moist; there is some pain 
on pressure all over the abdomen, but it is especially severe in the trans- 
verse colon and sigmoid flexure ; pulse moderately strong, but compressi- 
ble, and beats 110. The intellect is confused and weak, but this condi- 
tion is habitual to this woman, and is not connected with the disease. 

I now present a case of tubercular diarrhoea ; a disease having a close 
analogy to dysentery. The disease has continued for two months, the pa- 
tient having for some time previous been labouring under phthisis pulmo- 
nalis. Since the commencement of the diarrhoea the pain in the chest has 
continued, but the cough has declined, as almost always occurs in such 
cases. The diarrhoea seems to act uniformly as a revulsive, and stills the 
cough, or sometimes removes it for a time. The patient passes five or 
six stools daily; they consist of ordinary fecal matter, mixed with serum, 
but no mucus or blood. 

The diagnosis of dysentery is, in general, easy in acute cases. The tor- 
mina and tenesmus, and peculiar stools are sufficient to distinguish it. 
But in the chronic form of the disease the diagnosis is more difficult, as it 
is apt to be confounded with that form of diarrhoea which is produced by 
a tubercular condition of the follicles of the small and large intestine, and 
is usually preceded by a similar condition of the lungs. We are to distin- 
guish them by the history of the case. Tubercular diarrhoea is, in most 
cases, preceded by phthisis pulmonalis, that is, the disease generally begins 
in the lungs before it attacks the bowels. The discharges are generally 
irregular as to amount and frequency, and they differ in nature also from 
those of dysentery, as is proved by reference to the above cases. 

Anatomical lesions. — Dysentery is an inflammation of the large intestine, 
as is sufficiently indicated by the position of the pain. This inflammation 
and its consequences in some cases extend a short distance into the small 
intestine, and even to the stomach; but it always commences in the large 
intestine, and is generally confined to it. It mostlybegins towards the lower 
end of the colon, and is sometimes restricted altogether to within a short 



DYSENTERY. 697 

distance from the anus. The inflammation produces ulceration in various 
degrees; thickening of the mucus, and other coats; contraction of the cali- 
bre of the intestine, from the spasm of the muscular fibres ; and also slough- 
ing of the mucous membrane, which may thus be extensively detached. 
The mucous follicles suffer much from the disease, and the ulceration gene- 
rally begins in them, and then assumes a regularly rounded form ; then 
smaller ulcers run together, and finally give rise to the extensive destruc- 
tion of the mucous coat which occurs in most bad cases of dysentery. The 
anatomical lesions of this disease are of importance for the prognosis ; for 
when you have become familiar with them you may readily understand 
how slow the intestine is to recover its normal condition ; indeed, it is apt 
to remain for a long time more or less diseased, notwithstanding the dimi- 
nution of the symptoms. The contraction of the gut is one of the greatest 
obstacles to perfect cure when the ulceration has been extensive, for it can 
no longer bear the distension caused by the passage of fecal matter, and 
every new process of defecation is a new irritant to the denuded surface. 
It is, however, surprising to find that the intestine will sometimes, though 
rarely, regain a healthy state after the most extensive sloughing and ulce- 
ration. That is, it will regain very nearly a normal condition, but, per- 
haps, remain a little more irritable than usual. These remarks are appli- 
cable to the protracted cases of the disease, where the ulceration is deeply 
seated, and the powers of restoration have declined. When the disease 
is acute, the most extended ulcers will cicatrize kindly, and leave behind 
a smooth cicatrix, with puckered edges. These I have often seen months 
and years after an attack of acute dysentery, in patients who have died of 
diseases in no way connected with it. The depth of the»ulcers is, there- 
fore, more important than their extent. 

But the inflammation of the colon is not all ; there is something more ; 
and you will rarely find that patients can be said to labour under a local 
disease if the dysentery be severe. But although in the simple state it is 
certainly little else than a mere colitis, the complications render it danger- 
ous, chiefly because the blood and the cerebral system are involved. Still, 
the inflammation of the colon is, in all cases, the fixed anatomical character 
of the disease. 

Treatment of dysentery. — In the acute form of the disease, the treatment 
is sufficiently simple. The usual antiphlogistic means are required, with 
local applications to the inflamed mucous membrane, calculated to allay 
its irritability and remove its morbid secretions; these local remedies are 
narcotics and laxatives. In the practice of this hospital, especially during 
the present year, we rarely find it necessary to bleed. We give first a 
dose of castor-oil, and then make use of the oily mixture. Calomel, either 
alone, or combined with opium or ipecacuanha, is by far the best remedy 
in severe cases; we sometimes also use ipecacuanha alone, or Dover's 
powder. In most cases mercurials are sufficient to effect a cure as soon 
as they produce ptyalism, or just before, when the symptoms of acute dy- 
sentery often cease at once. Half, or a quarter of a grain of calomel, every 
two hours, will salivate in three or four days. It is usually combined with 
opium, to allay the griping, and prevent purging; or the pulv. ipecac, et 
opii may be employed in place of the opium, to effect the same objects. I 
also frequently use ipecacuanha, either alone, or combined with opium or 
calomel. In the case of subacute dysentery before us, I have employed 
these remedies, at times resorting to the acetate of lead, and various astrin- 



698 GERHARD'S CLINICAL LECTURES. 

gents, without much advantage ; Dover's powder has produced the most 
benefit. In the acute case you saw to-day, I gave half a grain of calomel, 
with three grains of Dover's powder, every two hours. 

I rarely employ calomel as a purgative in this disease. I use it for a 
few days only, to produce its specific antiphlogistic effect, — that is, until 
slight ptyalism is induced. If it is not then attended with good effects, 
it should be given up : a continuance of its use will do much injury, and 
tend to increase the ulceration of the bowels. 

This is a peculiarity in the action of mercurials ; in many acute inflam- 
matory diseases, the advantages to be gained are when the point of very 
slight ptyalism is reached, which is a test of the operation of the remedy, 
and the system may then be regarded as saturated. I am quite convinced 
that if, from any peculiarity of the system, or from the disease assuming 
an unusual tendency to the spreading of the ulcerations, mercury should 
be administered after ptyalism has been produced without benefit, the 
patient is decidedly injured. The remedy is best adapted to the inflam- 
matory forms of the disorder, and, as we shall presently see, is least fitted 
for the sloughing or malignant variety. 

Of the particular remedies in dysentery, purgatives have been exten- 
sively employed. We use many articles of this class in the hospital : the 
best is admitted to be castor oil, which purges sufficiently to carry off the 
vitiated secretions, without producing much irritation. To prevent the 
oil from acting too harshly, and to lessen the irritability of the bowels, 
laudanum may be advantageously combined with it. The oleaginous mix- 
ture is a good formula for their combination ; of this we give half an ounce 
every two hours*, till it begins to act on the bowels.* Rhubarb will also 
answer well as a purgative, and when the active symptoms have declined, 
the spiced syrup answers better than any other remedy. Venesection is 
sometimes required in acute dysentery, when the pulse is strong and 
corded ; but we have not found it necessary in any case which has occurred 
in this hospital during the present year. The epidemic character of the 
disease has not been of the violent inflammatory character, which is a 
cardinal point in the diseases of the mucous surface, and seems necessary 
to the perfect cessation of the disease. I would not have you to misun- 
derstand me — the term restoration of the secretions has been much abused 
and used vaguely. It means simply, in this case, to bring about the 
natural secretions of mucus, &c, in place of the diseased ones of blood 
and lymph. A certain set of remedies tend directly to produce this effect, 
and by restoring the natural secretions, they not only prove that the dis- 
ease is ceasing, but they contribute to its cessation by producing deple- 
tion in the most effectual way, that is, through the natural emunctories of 
the part. Cups and leeches to the abdomen, along the course of the 
colon, are also frequently advisable ; the latter may also be applied around 
the anus, for the purpose of drawing blood from the hemorrhoidal vessels, 

* In giving the oil mixture, it is important to select such a formula as will render it agree- 
able, or at least not disgusting to the stomach. The following is a good one : — R. 01 ricini, 
Ji. ; Tinct. card. comp.. gi. ; Aq. cinam., ^iiss. ; Gum acac. q. s. ad faciend mist. To the 
mixture we may add half a drachm, or forty minims, of laudanum — in a few cases even a 
larger quantity. The dose is a tablespoonful every two hours, or less frequently if the disease 
be declining. At the beginning of dysentery, when the stomach is quite healthy, it is better to 
give oil as a purgative, in doses of half an ounce, repeated once or twice, with ten to twenty 
drops of laudanum. At the end of the disease the bowels sometimes act irregularly, and the 
oil is then useful in very small doses, that is, a teaspoonful. 



DYSENTERY. 699 

and relieving the tenesmus. Warm fomentations are very often bene- 
ficially employed. But these measures, however important, cannot alone 
be relied on for the cure of the disease ; we must restore the secretions to 
their healthy condition. This is a principal, though not the only object 
for which we employ calomel, with opiates, &c. The action of opium in 
dysentery is peculiar : in the first place, it allays the local pain and general 
irritability; and secondly, it quiets the spasmodic movements of the 
intestine, and thereby facilitates the process of cicatrization. But it may 
likewise produce bad effects ; it tends to lock up the bowels, and prevent 
the discharge of the morbid secretions. To obviate this disadvantage we 
seldom use it alone, but combine it with castor oil, calomel, or ipecac. 
It may sometimes, however, be employed singly, either at the commence- 
ment or towards the close of the disease ; but never during the height of 
the inflammation. Opium is also used by injection. In this city, opiate 
injections in dysentery have not been much employed till within the last 
few years; and in the country their use is still very limited, but in this 
hospital we are in the habit of using them very largely. From twenty to 
forty drops of laudanum may be administered in this way, but not more, 
for dangerous consequences from time to time result from the frequent 
employment of large quantities of so powerful a narcotic, particularly 
when given by the rectum, in which mode of administration its action 
upon the brain is more irregular than when given in any other way. We 
usually inject twenty drops of laudanum mixed with a small portion of 
mucilage, every two, three, or four hours, according to the severity of 
the tenesmus and the effects of the remedy : thus, if the stools cease, or if 
the mind becomes confused, dull, or the patient sleepy, its use should be 
suspended. There is still another way in which opium may be employed 
in dysentery ; that is, by means of poultices sprinkled with laudanum, 
and applied to the abdomen, or to the anus.* 

Of the other remedies employed in dysentery, ipecacuanha, as we have 
already mentioned, is among the most useful. It is used either singly or 
combined with calomel or opium. A very effectual method of adminis- 
tering it, is in combination with extract of gentian and blue mass. This 
combination originated with Mr. Twining, and has been extensively and 
beneficially employed in India. It generally produces vomiting at first, 
but in a short time this effect ceases. I tried it largely in one epidemic ; 
its administration was followed by nausea and diaphoresis, and a consi- 
derable alleviation of the symptoms. It sometimes failed, but was gene- 
rally successful. The proportions are, six grains of ipecacuanha, four of 
blue mass, and five of the extract of gentian. 

Various other remedies have been employed in acute dysentery. They 
are principally antiphlogistics, such as saline purgatives, calomel in large 
doses, &c. These will doubtless answer in many of the ordinary cases of 
the disease. 

.Malignant dysentery is a form of the disease requiring considerable 
modification in the treatment. It occurs for the most part, in hospitals, ships, 
camps, &c. We had an epidemic of it in Philadelphia in 1837, and some 
cases in 183S ; it was so violent and so rapid in its progress as sometimes 
to produce gangrene of the intestines in two days. It is attended with 
great prostration of the vital powers ; subsultus tendinum, and various 

* This is very useful when the anus ami rectum are too irritable to bear the mechanical 
action of an injection. 



700 GERHARD'S CLINICAL LECTURES. 

other signs of debility and nervous disorder. All modes of treatment will 
frequently fail in this form of the disease. In the epidemic of 1837, we 
found it necessary to resort to stimuli, tonics and astringents ; as wine or 
brandy, cinchona or eascarilla, with the early use of kino, catechu, or 
chalk. Opium was also employed as a stimulus. 

Another variety is the subacute, of which we have an example in the 
first case above detailed. It occurs mostly in persons above the age of 
forty ; and often appears to be the effect of irregular habits, or of the 
gradual decline of the powers of life. In these cases, besides a regulated 
diet, we find Dover's powder to be the most effectual remedy ; it succeeds 
better than mercurials alone, but it may be combined with them, espe- 
cially the hydrargyrum cum creta, which is one of the mildest and best. 
I generally give it in three-grain doses every four or six hours. Cases of 
subacute dysentery are unfrequent in summer, being most commonly met 
with in the fall. We have had many cases of it in this hospital ; they 
have been principally confined to the lunatic wards — a circumstance which 
is explained by the debilitating effect which a disordered mind has upon 
the system. 

Besides the remedies already spoken of, the acids have, been largely 
used in the treatment of dysentery. This practice originated in tropical 
climates, where lime-juice, vinegar and other vegetables were employed. 
The use of the mineral acids was mainly introduced by Dr. Hope, whose 
mixture of nitrous acid, camphor and laudanum, has been of late years so 
extensively used in bowel diseases. It often produces the best effects, 
but will not answer in the sloughing form of the diseases. It proves 
most effectual in the subacute variety, and sometimes in the acute, after 
the severity of the case has declined ; but in the ordinary cases of acute 
dysentery, the benefit produced by this mixture is very problematical. 
The dose is about half an ounce every two or three hours. 

The acid practice is founded on a peculiar change in the symptoms of 
the disease which occurs in dysentery. The stool and saliva become 
extremely alkaline, and even the urine and perspiration lose to a certain 
extent or altogether their excess of acid. In giving the mixture I have 
usually continued its administration until the excessive alkalinity of the 
secretions diminished or altogether ceased. 

Chronic dysentery is another form which we frequently meet with. 
We have a case of it at present in a woman who has been suffering with 
it for six or seven weeks. There was griping in the region of the trans- 
verse colon, but during the last week it has been slight ; there have been 
three discharges in the last ten or twelve hours; the skin is dry and harsh ; 
the patient is much emaciated ; this form of the affection, indeed, produces 
more emaciation than any other disease except cancer. Chronic dysentery 
may last for years, and produce extensive ulceration or sloughing; and 
when even checked, is very liable to return. 

Treatment of Chronic Dysentery. — We must rely principally upon a 
regulated diet, of such a nature as will best agree with the patient ; for 
most persons farinaceous articles answer best, while others require animal 
food. Of the remedies to be employed, the best are opium and ipeca- 
cuanha with calomel, in minute doses. The nitrate of silver is often useful. 
In many cases, travelling by land or sea, particularly the latter, has 
operated very beneficially, by producing a general alteration and improve- 
ment in the system. This has been found to be particularly the case in 



DYSENTERY. 701 

the dysentery of the East Indies. Sea-bathing or sulphur-baths are also 
of great benefit. 

From the preceding remarks you will understand that our treatment of 
rlysentery must vary exceedingly in the different forms of the disease. 
The success of the treatment will, therefore, be various in different epi- 
demics. In the malignant, sloughing dysentery which occurs in camps, 
&c, the mortality is generally great, while, in some epidemics, it is com- 
paratively trifling ; we should not form a general opinion of the character 
of the disease from observation of a single epidemic, and still less, can 
we estimate the success of our treatment, unless it has been tested in 
various epidemics and in different years. A multitude of remedies are 
often prescribed and used with great benefit in the treatment of the dis- 
ease ; the limits of this lecture will prevent me from even mentioning the 
greater part of them, but they will be in general suggested by the peculiar 
symptoms of each case, and you will often succeed, in the most obstinate 
cases, by attending to some apparently unimportant particulars, such as 
the condition of the skin, or some slight change in the diet or mode of 
life of the patient. 

In laying so much stress upon mercurials, I do not wish you to under- 
stand that I am in the habit of administering these remedies carelessly, or 
with unnecessary frequency. On the contrary, I would not use them in 
dysentery when mild purgatives will cure the disease readily ; it is only 
in severe cases that I prefer the mercurial treatment, which is unquestion- 
ably the most effectual and most rapid means of getting rid of the dis- 
order. There is no necessity for producing decided ptyalism ; a slight 
action upon the gums is sufficient to test the effects of the remedy. 

I have explained to you the anatomical lesions at length, because your 
prognosis is, in severe cases, to a great degree, founded upon their extent, 
and you will perceive that a complete cure can only take place when the 
ulcerations of the intestine are healed. 



LECTURE XI. 

Subacute dysentery (continued) — Pathology and treatment — Phthisis pulmonalis. 

I shall bring forward to-day a case of the subacute form of dysentery, 
and afterwards several cases of phthisis, for the purpose of illustrating 
some of the various modes in which this disease commences. 

The case of dysentery is one of a class not unfrequently met with dur- 
ing the winter months, in which not only the bowels, but the mucous 
membranes generally, are affected. The patient is a man of nearly fifty 
years of age, and an habitual drunkard. A fortnight since he had an 
attack of delirium tremens, the symptoms of which continued during seve- 
ral days after his admission into the hospital. After an exposure to cold 
recently, he was seized with bronchitis, and the affection of the bowels 
for which he is at present under treatment. The alvine discharges have 
been very frequent, sometimes several in the course of an hour ; the pain 
was constant, but much more moderate than it usually is in the more 
acute variety of the disease. The character of the stools equally shows 



702 GERHARD'S CLINICAL LECTURES. 

that it is not a case of acute dysentery; they consist of ordinary thin, 
fecal matter, mixed with mucus, but at no time has either lymph, or blood 
been present. This case is a very good exemplification of the nature of 
the discharges in subacute dysentery, and the changes which occur in 
them at different periods of the disease. At first they are either sero- 
mucous, or thin and feculent : subsequently their consistence and appear- 
ance become altered, and they present the characters observed at the pre- 
sent stage of the case before us. Blood and lymph are very seldom to be 
found ; but in place of them, there is sometimes a grumous, fetid matter, 
resembling the scrapings of a disorganised intestine, which evidently re- 
sults from partial sloughing of the bowel. 

Although the stools differ so strikingly from those of the acute form of 
the disease, subacute dysentery is still an inflammatory affection ; but the 
degree of action is moderate, on account either of the debilitated condi- 
tion of patients labouring under it, from old age, or irregular habits, or of 
the epidemic constitution of the season. A constitution of this sort, in- 
deed, appears to prevail at present, imparting to epidemic diseases a ten- 
dency to assume more or less of the characters of the case which we are 
considering. 

The principal features of the case are as follows : (Complete notes 
were not preserved.) 

J. G., admitted November 25th. The bowels are loose ; there is 
cough, with whitish expectoration ; patient much debilitated. The olea- 
ginous mixture was administered, and a small quantity of milk-punch was 
allowed. 

26th. The punch discontinued. 

28th. Dysenteric symptoms more severe ; twelve discharges from the 
bowels in the course of five hours ; stools thin and watery, with very 
little feculent matter, but very fetid ; slight pain on pressure over the ab- 
domen ; cough continues ; mind confused and agitated. Six ounces of 
blood taken by cups placed over the colon, and the following combination 
prescribed : 

R. Pulv. Ipecac, et Opii, gr. vj. 
Hydrarg. Submuriat. gr. j. 
Ext. Krameriae, gr. v. M. 

To be repeated every three hours. Blisters also applied to the abdomen. 
29th. The Dover's powder and rhatany in the above prescription 
were diminished to three grains each, and the calomel to one-eighth 
of a grain. It was found necessary to reduce the Dover's powder, be- 
cause it produced some symptoms of narcotism ; that is, contraction of 
the pupil, and confusion of mind, without diminishing the frequency of 
the stools. When such a state of things occurs, you must either dis- 
continue opiates, or reduce the quantity administered ; else the nar- 
cotic may accumulate in the system, and cause the patient to sink sud- 
denly and almost imperceptibly. In the earlier stages of acute dysentery, 
opium may often be given very largely without producing its characteristic 
effect. A case of this variety occurred a few years since in one of the 
resident physicians of this hospital. He was attended by Dr. Horner and 
myself, and the quantity of opium was gradually increased to thirty grains 
a-day before the least effect was produced. But in the subacute form we 
cannot employ such large quantities with safety, and the remedy should 
be withheld, or its dose diminished, as soon as it produces its specific 



DYSENTERY. 703 

effects. You must recollect, too, that even in the acute form of the dis- 
ease, you must give it very cautiously ; for mischief may in any case re- 
sult from it, if administered in a careless or rash manner. The rule is, to 
increase it gradually, and watch carefully its effects ; suspend it altogether, 
or diminish it greatly, the moment you find any signs of narcotism. 

The Dover's powder and calomel have been the active remedies used 
in the treatment of this case ; the extract of rhatany has been productive 
of no very decided benefit. The good effects of mercury in this disease 
(as remarked in a previous lecture) coincide with the occurrence of slight 
ptyalism, — which I find, upon examination, to have taken place in the 
patient before us. If it procures no amelioration of the symptoms at this 
characteristic period of its operation, mercury should be discontinued ; and 
in all cases where there is sloughing of the mucous membrane, and a gan- 
grenous fetor of the discharges, its use should be avoided, as it then un- 
doubtedly tends to aggravate the severity of the disease. 

You must have remarked that stimuli were employed in the early treat- 
ment of this case. The patient came in much debilitated from the effects 
of delirium tremens and previous dissipation, and a small quantity of milk- 
punch was therefore allowed. In all cases of this disease, indeed, in which 
there is an enfeebled condition of the vital energies, it is necessary to use 
stimuli. This is particularly true of the malignant or sloughing variety of 
dysentery, between which and the subacute there is an intimate connec- 
tion. The latter has a constant tendency to pass into the former; and from 
what has so frequently occurred in camps and hospitals, I have no doubt 
that the present case would assume the malignant form, if there were many 
of a similar character in the wards at the same time. If such a change 
should supervene, it would be necessary, as I have already remarked, to 
discontinue the use of mercurials, and to rely principally upon Dover's 
powder and stimuli. 

The cupping in this case produced only moderate benefit, whereas the 
blister operated very advantageously. It is one of those instances of mo- 
derate, but obstinate inflammatory action, to which blisters are so pecu- 
liarly adapted. Cupping or leeching would be better in the more violent 
and acute cases of dysentery. 

The woman who was brought before you two weeks since as a case of 
acute dysentery, and was treated with mercurials, is now quite well. The 
man who was labouring under the subacute form of the disease, at first 
improved considerably, by the use of Dover's powder and astringents, but 
afterwards sank again, and died on the 28th inst. The results of the post- 
mortem examinations are as follows, and show the cause of death. 

The following lesions are met with in the intestinal canal. 

The mucous coat of the rectum is of a bluish colour, and softened. As 
we pass up the colon, we find extensive ulcerations, some of which are 
cicatrized. There is a large cicatrix near the sigmoid flexure; the newly- 
formed membrane is thin and bluish; the old membrane, on the contrary, 
is much thickened, and to a still greater degree are the cellular and muscular 
coats. Farther up the ulcers are scattered about, of small size; the mu- 
cous membrane softened. Near the caecum the morbid changes are of 
more recent date ; the mucous membrane is highly injected, and patches 
of lymph are here and there observed. The ulcers are in the acute stage 
of their progress ; they are of a rounded form, and are seen to have com- 
menced in the follicles of the intestine. We have here exemplified the 



704 GERHARD'S CLINICAL LECTURES. 

different appearances in the acute and chronic forms of dysentery ; in the 
upper part of the colon, where the former condition prevailed, the mucous 
membrane is of a bright red colour, as in acute inflammation of this tissue 
generally; but in the lower part, where the disease had become chronic, 
the colon is bluish. This examination also illustrates a remark which I 
made in a former lecture, that dysentery usually commences in the lower 
portion of the colon, and proceeds upwards in its course. 

The disease has also passed into the ileum, which is in a state of acute 
inflammation. There are bright red spots and patches of lymph, scattered 
over the mucous membrane, for some distance from the ileo-caecal valve. 
The glands of Peyer are altogether or nearly intact; in which circumstance 
you perceive a striking difference from the inflammation of the ileum which 
occurs in typhoid fever. This acute inflammation of the small intestine, 
supervening in the course of the dysentery, was the immediate cause of 
death. The mucous membrane becomes gradually more healthy as we 
ascend, but is more or less softened. 

The stomach also presents marks of inflammation. At the splenic ex- 
tremity the coats are very thin, and much softened : this condition was in 
a great measure produced by the action of the gastric juice, which had 
become altered in constitution, and excessively acid ; the membranes at 
this point have an acid smell, and produce an unusually powerful reaction 
upon test paper. Throughout the remaining portions of this viscus the 
coats are white and opaque, from an alteration both in the fluids and the 
structure. There are dark red patches in several places. Near the pylo- 
rus there is a puckering of the mucous membrane, produced by a cicatrix. 
This membrane is generally softened, but the colour is not particularly red- 
dened. The coats of the pylorus are thickened and indurated, and there 
is a scirrhous formation in the cellular tissue ; its fibrous character is, how- 
ever, not yet distinctly marked. The symptoms produced by scirrhus of 
the pylorus, are difficulty of digestion, and vomiting from time to time, 
which may be so severe and repeated as to produce death. It may be re- 
marked that these scirrhous affections are frequently developed in consti- 
tutions where the diathesis has been latent, by depression of mind, parti- 
cularly in old persons. This is illustrated by the instance of Napoleon ; 
and I recollect an equally striking case occurring in a Swiss emigrant. 

The liver is also affected in the present case, but lesions of this organ 
accompany dysentery far more frequently in hot than in cold and temperate 
climates. Its colour is a pale yellow, and it appears to be in the first stage 
of that alteration called the fatty degeneracy. The tests of this condition 
are the greasy appearance of the scalpel when drawn through the substance 
of the liver, and the bright flame produced by burning a piece of paper 
which has been moistened with the fatty fluid. The acini are also ob- 
served to be very distinct, and surrounded by vessels, producing an ap- 
pearance of great vascularity and incipient inflammation of the liver. The 
fatty degeneracy in this case was probably produced by the habitual in- 
temperance of the patient, and subsequently increased by the dysentery. 

The spleen, which is so often found greatly enlarged and softened in 
various diseases, is here nearly of the natural size, but the texture is soft- 
ened. The cause of this change in the spleen is not well understood, 
but it appears to be in some way connected with an alteration of the blood. 
The spleen probably performs an important part in the formation of this 
fluid ; but what the precise office is, cannot be yet ascertained. 



PHTHISIS PULMONALIS. 705 

From this examination you will perceive how readily the most exten- 
sive ulcerations of the mucous membrane of the intestine will cicatrize, 
provided the muscular coat is not exposed by them. 

PHTHISIS PULMOXALIS. 

I next proceed to bring to your notice several cases of phthisis pulmo- 
nalis, with the view of exemplifying some of its modes of origin : — this is 
the more appropriate, as the present season (November) gives rise to few 
acute diseases. 

Case 1st. — You may recollect that this man came before you on the 
23d inst., with many symptoms resembling those of intermittent fever. 
Since that time the skin has continued hot, with occasional sweats ; the 
pulse has usually beaten one hundred and sixteen in the minute ; yester- 
day, ninety-six; it is also quick and irritable, jerking, and easily felt, but 
small and not corded. This character of the pulse is often important as 
a diagnostic sign ; it occurs in chronic diseases, or in acute diseases gra- 
dually passing into a chronic state, accompanied by a general disorder of 
the system. It is most frequently observed in incipient phthisis, particu- 
larly when this disease is attended by pleurisy. The respiration is, also, 
much more hurried than natural, being performed from thirty to thirty--ix 
times a minute. Cough frequent; expectoration thin, white, and small 
in quantity ; tongue at present somewhat pale, and gradually cleaning. 
The respiration is resuming its natural character in the lower part of the 
right lung, owing to the decline of the pleurisy ; but it remains rude in 
the upper lobe of the lung ; a sign corresponding to the tuberculous con- 
dition of the part. The action of the heart continues exaggerated, and 
the second sound is still absent. The difficulty of walking also continues, 
but in a somewhat less degree ; it is dependent on an acute affection of 
the spine. 

The treatment of this case has consisted in the application of a blister 
to the cardiac region, and the administration of digitalis and Dover's 
powder, in the proportion of one-third of a grain of the former to three 
grains of the latter, the dose being repeated four times a-day. Considera- 
ble advantage has resulted from these measures ; the inflammation which 
had existed being in a great measure overcome, and the inordinate action 
of the heart diminished. The digitalis and Dover's powder were given 
particularly with a view to the latter effect, and to allay the irritability of 
the pulse. This combination sometimes produces a dryness of the mouth, 
and of the alimentary canal generally, which is unfavourable to the due 
performance of the digestive functions : but it is by far the best mode of 
administering these remedies. 

I have introduced this case as an example of tubercular disease com- 
mencing with pleurisy. The tubercular deposition seems to be a result 
of the inflammation, as truly as are its ordinary consequences, effusion, 
adhesion, &c. In most patients the latter conditions would be the only 
effects of the inflammation ; but in the present case there existed a cachec- 
tic condition of the system, predisposing it to the development of phthisis ; 
hence this disease followed as a consequence of the inflammation. The 
inflammation which thus produces phthisis, may be seated in any of the 
tissues of the lungs : thus, it may be a bronchitis or a pneumonia, as well 
as a pleurisy. But it usually affects a serous membrane ; therefore, pteu- 
46 



706 GERHARD'S CLINICAL LECTURES. 

risy is more frequent than the other pulmonary inflammations preceding 
phthisis, just as peritonitis also is often the primary lesion in tuberculous 
deposits in the peritoneum. But these cases of inflammatory phthisis are 
by no means so frequent as those which commence gradually and slowly. 
Of this more common form we have an example in the next case. 

Case 2d. — The patient, who is a printer, has for a long time had a 
slight cough, and other symptoms of incipient phthisis. During the last 
summer, there was a great aggravation of all the symptoms, accompanied 
by a slight inflammation of the bronchial tubes ; and the patient is now 
scarcely able to leave his bed. In this case, it is evident that the inflam- 
mation was the consequence, not the cause of the phthisis, as in the pre- 
ceding case. With regard to those cases of phthisis which I suppose to 
be caused by inflammation ; it may be argued by those opposed to this 
view of the origin of the disease, that the phthisis existed, but in a latent 
form, previously to the commencement of the inflammation. But those 
cases are exceedingly rare, in which the disease does not declare itself, 
either by some symptoms, or by physical signs. Hence, I feel compelled 
to believe, in contradiction to my former opinion, that phthisis may arise 
from inflammation, occurring in constitutions predisposed t.o the formation 
of tubercles. 

Case 3d. — This woman has had a slight cough for four years ; about 
three months since, after exposure to wet and cold, the cough and other 
symptoms were greatly aggravated. These circumstances are sufficient to 
show that, in this case also, the inflammatory symptoms supervened in the 
course of the phthisis, instead of preceding it. 

Case 4th. — This woman also has had a cough of four years' standing, 
w r hich became very bad during the summer; after working in an exposed 
situation. During the last week there have been flying pains under the 
ribs of the right side. These pains arise from the slight and shifting 
pleurisy so often met with in cases of tubercular disease. These pleurisies 
are generally dry ; that is, unattended by effusion of serum. The expec- 
toration is copious ; the sputa are in round masses, and of the kind called, 
from this circumstance, nummular; they usually sink in water, but some- 
times float from their containing particles of air ; they consist of pus, 
mixed with mucus, and sometimes a portion of broken-down tubercular 
matter. 

In both these women, the skin has assumed a dusky, earthy colour, 
entirely distinct from the paleness which accompanies it ; this hue is almost 
peculiar to phthisis. The sclerotica has that light blue tinge which is so 
frequently met with in constitutional cases of phthisis. The appetite has 
remained good ; indeed a good appetite, persisting for a long time in a 
patient affected with cough, and gradually becoming thin and pale, is one 
of the most constant indications of commencing phthisis pulmonalis ; in 
many cases the appetite is morbidly great. One of the patients is jaun- 
diced. This probably arises from a fatty degeneracy of the liver, accom- 
panied by enlargement ; a condition very frequently occurring in this 
disease ; more particularly in female patients. The jaundice arising from 
this cause must be carefully distinguished by the practitioner from that 
which depends upon primary affections of the liver, and is totally uncon- 
nected with any disease of the lungs. I have seen many cases of phthisis in 
which the liver was supposed to be the sole cause of the mischief. It is 
true, that in a large proportion of these patients the liver was fatty, but 



PHTHISIS PULMONALIS. 707 

this condition arises from the phthisis, and is neither a primary lesion, 
nor one in itself of much importance. 

Case bth. — This man has been very recently admitted into the hospital. 
He is much emaciated, and has had a cough for four weeks ; the disease 
is therefore probably phthisis. This probability is rendered almost certain 
by the respiration being very deficient under one clavicle, and feeble 
under the other also. But there are as yet no signs of the existence of a 
cavity. The patient's account of the manner in which the disease com- 
menced, is this: After having been engaged at hard labour, out of doors, 
during the day, he was awakened from sleep in the night by a sudden fit 
of coughing and haemoptysis ; in a short time he discharged in this way a 
pint of blood. The haemoptysis lasted several days ; but for the last three 
weeks the sputa have contained no blood, but only a frothy matter. This 
is an example of the hemorrhagic variety of phthisis. The hemorrhage 
with which the disease commenced arose from the mucous membrane of 
the bronchial tubes. In such cases the hardening of the pulmonary 
tissue, from the deposition of tubercular matter, does not generally com- 
mence early in the progress of the disease ; or rather, it does not soon 
proceed to a high degree of induration in any particular portion of the 
lung. 

The patient is a shoemaker: and we may remark that shoemakers are 
particularly subject to phthisis, from the confined and sedentary nature of 
their occupations. His constitution has always been delicate ; but he has 
never before had cough or pain in the chest, except after occasional ex- 
posure to cold. Immediately previous to the present attack, he was in the 
enjoyment of his usual degree of health. 

Case 6th. — The patient is, like the last, a shoemaker by trade, aged 
42. He has had cough for nearly two years, but it has been generally 
unattended by pain ; there has been merely a sense of oppression at the 
lower end of the sternum. In February, 1838, he had an attack of 
pleurisy, which left behind it the usual signs of contraction of the chest. 
He had no cough previously to the attack of pleurisy, except for a short 
time, about six months before, and occasionally during spells of inter- 
mittent fever. The case, therefore, appears to be one of the inflammatory 
variety of phthisis, having been preceded, as in the first of these cases, by 
inflammation of the pleura. 

Caselth. — This is another example of phthisis commencing suddenly, 
with an attack of inflammation. The patient, a man 41 years of age, has 
had cough for eighteen months ; it began after he had been working at 
the engines at a fire ; had previously been a stout, healthy man, and had 
never had a cough of any duration. The attack was one of considerable 
severity, but the patient was not confined to bed by it ; he did light work 
for a year afterwards, but for the last six months, has been unable to per- 
form any kind of labour. He is much emaciated, and presents all the 
signs of confirmed phthisis. 

The cases of phthisis arising from inflammation are much more fre- 
quently found in men accustomed to hard labour than in others, and espe- 
cially in those past the age of five-and-thirty. In younger persons, espe- 
cially females, the disease is more frequent, and more commonly begins 
in a slow and insidious manner; inflammation may, and often does occur 
in those cases, but then it is strictly secondary, and depends either upon 
the irritation of tubercles in the lungs, or the accompanying fever. 



708 GERHARD'S CLINICAL LECTURES. 

There are cases in which phthisis becomes a local disease only at a very 
late period, remaining for a long time constitutional, and apparently de- 
pendent, partly on the nervous, but, in a greater degree, on the vascular 
capillary system. 

Case 8th. — There are three modes in which phthisis commonly com- 
mences : first, slowly and gradually, indeed almost imperceptibly ; secondly, 
preceded by inflammation ; thirdly, commencing with a sudden attack of 
haemoptysis. This case is an instance of the third variety of the disease — 
the hemorrhagic. The patient entered last Saturday; he is a weaver by 
trade. This employment is a frequent predisposing cause of phthisis, from 
the circumstances in which weavers are placed. They work in close rooms, 
much the same way as shoemakers and printers, and fatigue excessively 
the thorax. There are other circumstances which aid in producing this 
predisposition in weavers ; such as long confinement in one position, the 
dampness of the cellars in which they generally work, and the breathing 
of an atmosphere loaded with irritating effluvia, which arise from the 
woollen and cotton goods. The patient had been in good health pre- 
viously to the present attack; had never had a severe cough for any length 
of time, and had been temperate in his habits. His parents are still alive 
and healthy, so that the predisposition is probably not an hereditary one ; 
though instances are occasionally met with in which consumption passes 
by one generation, and is transmitted from grandfather to grandson, with- 
out any indications of its presence at the intermediate point. The account 
given by the patient of the manner in which he was attacked, is this: — In 
February last, while engaged at work, he was suddenly seized with spit- 
ting of blood ; in the course of a fortnight he discharged in this way a 
very large quantity of blood; he thinks it amounted to six quarts, — but 
this estimate is, no doubt, much exaggerated. At last he coughed up a 
large coagulum of blood, by which he was nearly suffocated. From this 
time the haemoptysis ceased, but the cough continued without intermission ; 
the sputa are whitish and muco-purulent. About five months since, he 
began to be weak and emaciated, and has become more and more so ever 
since. Chills also commenced with the cough, and have constantly ac- 
companied it up to the present time. This is, therefore, another of those 
cases of phthisis which simulate intermittent or remittent fever at their 
commencement, and of which I have already spoken in the two preceding 
lectures. The tubercular fever, causing this resemblance, occurs in the 
earlier stages of phthisis, and is truly an irritative disease. Sometimes it 
assumes the remittent type. I have known two cases of this sort amongst 
my own acquaintances, which were mistaken for remittent fever, and 
treated as such; but, after some time, the true nature of the affection was 
explained, by the clear development of the local signs of phthisis. In the 
present case there would have been little difficulty in the diagnosis, for 
the hemorrhage would have made the character of the fever clear. But, 
in the majority of cases where haemoptysis does not precede the tubercu- 
lous disease, you will be often aided greatly in your diagnosis by the cha- 
racters of the fever. 

The patient has also suffered from profuse night-sweats, and here we 
have a circumstance which distinguishes this fever from hectic. In the 
latter, the sweating is not so profuse as in the former ; but the chills, on 
the contrary, are more severe. The patient's appetite has been bad for 
four or five months; he has had several attacks of diarrhoea, continuing 



PHTHISIS PULMONALIS. 709 

two or three days at a time. Diarrhoea is a common attendant of phthisis 
pulmonalis, and generally arises from the deposit of tuberculous matter in 
the small intestines simultaneously with the same process in the lungs ; but 
the frequency and duration of its attacks vary greatly in different cases. 
You have remarked that the patient w T as seized with haemoptysis while at 
work; it is in this way that it often begins, — suddenly, and while the chest 
is exposed to some strain. 

Hemorrhage from the lungs, occurring in this sudden manner, is, in 
most cases, a sure sign of phthisis pulmonalis. It may sometimes arise 
from other causes, as disease of the heart, congestion of the lungs, or a 
mechanical cause, such as a strain ; but in five cases out of six, in men at 
least, it is followed by the local signs of tubercular disease. In women, 
however, it is not so valuable as a diagnostic sign ; for in them it may 
follow suppression of the menses, and may, in fact, become a vicarious 
discharge. Though haemoptysis may arise, as I have said, from a sudden 
muscular effort, when there are no tubercles in the lungs, — yet, in the ma- 
jority of such instances, they either exist already, or there is a tendency to 
their formation ; for whenever such a tendency exists, the bronchial mu- 
cous membrane will bleed from very slight causes. I recollect an instance 
in which the haemoptysis was caused by jumping over a wall about five 
feet in height, and was followed by all the signs of phthisis ; and another 
in which it occurred from lifting a gate which had fallen. The tubercular 
diathesis, therefore, predisposes to hemorrhage from the lungs. It is true, 
that not a few cases of haemoptysis abort, as it were, before the tubercles 
are secreted to any amount; but when we find that the majority of patients 
in whom this symptom occurs, are afterwards affected with confirmed 
phthisis, it is perfectly consistent with the facts to believe that the hemor- 
rhage coincides with a condition of lungs which favours the tuberculous 
secretion, and which had in many cases given rise to a limited deposit of 
tubercles before the discharge of blood took place. 

Of the tubercular fever, which is an attendant of the disease in the pre- 
sent case, I have spoken more fully in the preceding lectures. The other 
general symptoms present nothing peculiar. The emaciation, you per- 
ceive, is considerable, and is accompanied by that dirty, earthy hue of the 
skin (more especially of the face), which you have seen in several other 
patients. 

The local signs are — 1, cough; 2, expectoration: this at first consisted 
of mucus, afterwards becoming muco-purulent, with portions of broken- 
down tubercles; 3, dulness on percussion under one of the clavicles, with 
mucous rhonchi, and a commencing cavernous respiration. These last 
signs indicate the stage of the disease; they show that there is already 
some softening of the tubereular matter. This fact is also proved by the 
character of the sputa. 

Case 9th. — This patient has been a labourer on the canal. Before the 
present illness he never had a cough, or any other sign of pulmonary dis- 
ease. He has been sick for two years : the attack was gradual, and was 
produced by taking cold. Since that time there has been constant cough 
and expectoration ; the matter of the sputa is at this time muco-purulent, 
and somewhat nummular, and begins to be characters ic of this disease. 
Emaciation has been apparent for eight months: before this attack, the 
patient was a stout man. The skin is dry, pale, and dusky. There has 
been one attack of diarrhoea. There was fever, with profuse night-sweats, 



710 GERHARD'S CLINICAL LECTURES. 

but no chills : it is therefore a modified form of hectic. At present there 
is not much fever — pulse 94. The expectoration consists of round masses 
floating in a thinner liquid, with small pieces of tubercular matter : at 
first it was raucous, then muco-purulent. The sputa takes its shape from 
the cavities in which it is found. We shall presently see that when these 
cavities are very large, the nummular character is no longer present. 
There has been no haemoptysis until two nights since, when about a spoon- 
ful of blood was discharged. Such small quantities are not important ; 
they may arise from irritation of the bronchial membrane, and it is only 
when haemoptysis is considerable, that it becomes a sign of importance, 
and also pathognomonic of phthisis. 

Case 10th. — This patient was brought before you at the last lecture, as 
an example of tuberculous disease, coinciding with inflammation of the 
serous membranes. Since that time, the breathing has continued much 
oppressed ; tongue dry and red ; pulse, 95 to 104 ; bowels constipated. 
The vesicular murmur has become more distinct on both sides of the chest. 
There has been an increasing pain in the praecordial regions, with a bruit 
de soufflet of the heart ; respiration frequent and high. Yesterday, for the 
first time, I discovered a grating or creaking sound of the heart, indicative 
of pericarditis ; the creaking being produced by lymph into the pericar- 
dium. The two surfaces of this membrane rub against each other, chiefly 
at the beginning of the diastole of the heart, and a grating sound is pro- 
duced by the spiral movement of the heart on its axis, during the dilata- 
tion of the ventricles. The patient, you will recollect, was first attacked 
by pleurisy ; since then, pericarditis has supervened, with more or less 
endocarditis. This case is, therefore, a good illustration of a circumstance 
to which 1 called your attention when I first brought it before you ; the 
connection between phthisis and inflammation of serous membranes. This 
patient has inflammation of all the serous membranes of the chest, occur- 
ring in succession. The pleurisy has declined as the pericarditis super- 
vened. Besides the signs already mentioned, the existence of pericar- 
ditis, attended with effusion, is indicated by feebleness of the impulse of 
the heart, flatness on percussion (extending over a larger space than that 
occupied by the natural dulness of the heart), and pain on pressure or 
percussion. The latter symptom, however, is not always present in peri- 
carditis ; in any of the serous membranes, in fact, inflammation may 
occur without the ordinary signs. But in this patient the flatness extends 
to at least double the usual spaces, and there is very decided pain at the 
region of the heart, which is increased by slight pressure, but is always 
more or less felt. The dyspnoea in this case is dependent partly on the 
pleurisy, partly on the pericarditis. The pulse is not invariably altered 
in inflammation of the heart or its membranes ; it is principally affected 
in endocarditis, which gives rise to more or less obstruction of the valves. 
In the present case, there is excitement of the pulse and slight irregu- 
larity. 

I shall now show you some cases of gangrene of the lungs, and bron- 
chitis, the symptoms of which more or less resemble- those of phthisis, and 
the diagnosis becomes, therefore, frequently difficult. 

Gangrene of the lungs is by no means a frequent disease, it is oftener 
met with in hospitals than in private practice. It resembles phthisis, in- 
asmuch as it produces softening of the pulmonary tissue, and, conse- 
quently, the formation of cavities. It differs from it in the fetor of the 



GANGRENE OF THE LUNG?. 711 

breath, and expectoration. The local signs, at the commencement of the 
disease, are imperfect. 

The causes of gangrene of the lungs are cold, an epidemic tendency of 
the atmosphere, intemperance, and depressing circumstances generally. 
In most cases, it arises from direct exposure, but sometimes it comes on 
gradually, and appears to be part of a general disease ; that is, it depends 
on a vitiation of the fluids, in the same way with dry gangrene, of which 
I have shown you an example. 

Case. — The patient is a boatman, forty years of age. He had enjoyed 
good health till about two months before his entrance into the hospital. 
At that time, being engaged at his occupation on the Schuylkill, he fell 
into the river, and was with difficulty saved from drowning. He felt ex- 
tremely cold, and could not speak for twenty minutes, but no sigu of 
active disease followed for two weeks, other than feebleness and chilli- 
ness. Then a cough began, accompanied by pain in the lower part of the 
right axillary region ; the sputa have never contained blood, and have 
been fetid from the beginning; appetite has been bad throughout; the 
patient continued to work regularly until November 30th ; but since that 
time he has been unable to perform any kind of labour. The treatment, 
previously to his entrance into the hospital, consisted of venesection, and 
the application of a blister to the right side of the chest. 

The patient was admitted December 6th. At that time the symptoms 
were as follows : slight emaciation ; a dusky hue of the skin ; slight flush- 
ing of the face ; dilatation of the nostrils ; skin warm ; pulse 104, thrill- 
ing, moderately resisting ; respiration 22, high and laboured ; expectora- 
tion thick and homogeneous, of a dirty, greyi>h colour, and very fetid. 
On the right side, anteriorly, respiration vesicular throughout, with traces 
of the mucous rale, hurried and harsh at the summit of the lung. On 
the left side, vesicular, with traces of both mucous and sonorous rhonchi. 
Posteriorly, on the right side, vesicular in upper lobe, hurried, and very 
feeble ; in lower lobe, scarcely any vesicular sound ; at the upper part, 
deep-seated, cavernous respiration, and imperfect pectoriloquy. Percus- 
sion gives a flat sound in the lower two-thirds of right side posteriorly ; 
clear anteriorly. The signs, therefore, indicated a cavity in the lower 
lobe of the right lung, with an engorged condition of the surrounding tis- 
sue, accompanied by pleurisy. The treatment consisted in the use of 
chloride of soda, given in doses of twenty drops four times a-day, with 
nourishing diet. Quinine, porter, and brandy are often necessary ; the 
indications being to correct the fetor of the breath and expectoration, and 
support the system, while nature effects the elimination of the gangrenous 
tissue. A number of palliatives, such as opiates at night, will doubtless 
occur to you ; but you should be sparing of depletory measures ; they are 
rarely necessary, except when there is severe pleuritis near the gangrene ; 
and these should be limited to local bleeding, or, still better, to blisters. 

Gangrene of the lungs is to be distinguished from phthisis by these cir- 
cumstances: it usually begins suddenly, and runs its course rapidly ; the 
skin presents a more decidedly dusky hue in gangrene than in phthisis ; 
and the breath and expectoration are always fetid from the commence- 
ment of gangrene. The prognosis of the two diseases is also very dif- 
ferent. Jn gangrene, it is not necessarily unfavourable ; from one-third 
to one-half of the cases recover ; in phthisis, on the contrary, our prog- 
nosis is almost always unfavourable after a cavity is formed. When gan- 



712 GERHARD'S CLINICAL LECTURES. 

grene tends to a favourable termination, recovery generally takes place in 
a few weeks. Any improvement in the symptoms of phthisis, on the con- 
trary, is very gradually and slowly effected. 

There are two kinds of expectoration met w T ith in gangrene of the 
lung. The most common is blackish, and resembles an inky sediment. 
The other kind, of which we have an example in the present case, is a 
greyish, frothy fluid, having some resemblance to yeast, with a fetid 
odour, which you may perceive is like that of putrid oysters. This, 
though the least common, is the most favourable variety of sputa. It is 
generally discharged in very large quantities — amounting, sometimes, to 
a pint or a quart daily. 

I have frequently described, in my lectures, the progress of cure in 
gangrene. When the sphacelated portion is thrown off, a cavity is formed, 
lined with the usual pus secreting false membrane, which gradually as- 
sumes the character of a mucous membrane. We shall watch the pro- 
gress of this case, and keep you informed of the result. 

The next case is one of bronchitis. The patient is a labourer, aged 35 
years. He entered the hospital on the 2d instant, having been ill for two 
weeks. He w T as seized with cough, and pain along the sternum ; in the 
course of a week, he began to expectorate a muco-purulent matter, con- 
taining no blood ; during the most of the time he has been confined to 
bed. These signs indicate an acute disease, which might be mistaken 
for the acute form of phthisis. It is distinguished from it, by the absence 
of the irritable, jerking pulse of phthisis, described in our last lecture, 
and also, by the absence of the local signs of tubercular deposition. Thus 
there is no flatness on percussion under the clavicles ; and the mucous 
rhonchus is heard in the sound of respiration throughout the lower lobes 
of both lungs. But though bronchitis is thus distinguished from phthisis 
in the commencement, both by the general and local signs, yet it is very 
apt to terminate in the latter disease, and w r e ought always to anticipate 
such a result when it is prolonged, and occurs in young persons. 

The next case is a complication of phthisis and bronchitis. The patient 
is a boatman, 38 years of age, of intemperate habits. He had been sick 
for three months, and unable to work during the whole of his time: his 
illness was caused by falling into the canal : the next day he was seized 
with shivering and cough, unaccompanied by pain : the expectoration 
consisted of mucus mixed with pus, but no blood. On the 4th inst. he 
entered the hospital, and the symptoms were as follows: — There w T as 
abundant mucous rhonchus throughout both lungs, passing in certain por- 
tions into the sub-crepitant, while at the summit of the left lung, the per- 
cussion is dull and the respiration extremely bronchial. There is a quick, 
irritated pulse, some emaciation, and a dry, dusky skin. The sputa, 
although not nummular, are more purulent than is usual in most cases of 
bronchitis. The dyspnoea is much greater than in most cases of phthisis 
or uncomplicated bronchitis. 

This case began in the form of bronchitis : phthisis was developed sub- 
sequently, and the two diseases are now co-existent. This state of things 
is of frequent occurrence, particularly at advanced periods of life. At an 
earlier stage, when phthisis is developed in the course of a bronchitis, it is 
apt to commence more suddenly, and run its course more rapidly than in 
the present instance. The patient, you perceive, is but slightly emaciated, 
and will probably get comparatively well: that is, the disease may con- 



PHTHISIS PULMONALIS. 713 

tinue for years, with slight cough, &c, but may not shorten the patient's 
life ; the cavity in the lung remaining, but lined with a healthy membrane. 
I have known several cases of such comparative recovery from this form 
of disease ; and the chances of long life are not afterwards apparently 
affected by it. 

I repeat that phthisis pulmonalis may commence in several different 
forms : 

1. It may commence slowly and gradually. This is the most common 
mode of origin, and is generally met with in cases where the tubercular 
diathesis is hereditary. The first symptoms of the disease are slight cough 
and expectoration ; the local physical signs are not present until a more 
advanced stage. 

It is very clear that in most of these cases the phthisis is nothing but a 
mode in which the general tuberculous disorder manifests itself, and that 
the disease can scarcely be considered local, although the largest deposit 
of tubercles is in the lungs, or perhaps the only deposit. In many of them 
no antecedent cause can be detected, in others something has produced a 
debilitating effect upon the constitution, such as grief, indifferent diet, 
confinement, &c, and the natural tendency to phthisis is called into 
action, or a new disposition to it is developed. 

2. Phthisis may arise from inflammation. This variety is most common 
in robust persons, and is likewise, in most instances, dependent upon here- 
ditary predisposition, which imparts to inflammation a tendency to termi- 
nate in the formation of tubercles. The most common seat of the inflam- 
mation preceding phthisis, is some one or other of the serous membranes; 
and the tubercles may at first be deposited either in the serous membranes 
alone, in the lungs, or in both. The mucous membrane of the bronchial 
tubes may likewise be the seat of the inflammation; but phthisis beginning 
in the latter way, is more commonly met with in old persons, than that 
which begins by the serous membranes. 

Inflammation performs two distinct parts; in the first it is properly the 
cause of the tubercular deposition, which may occur some time after the 
inflammation, or take place during its progress. In the second, the secre- 
tion of tubercle is attended or followed by an acute inflammatory action in 
the organs, but the cause of the tubercles cannot be said to be the inflam- 
mation which attends their secretion. 

These inflammations often present some peculiar features, even when 
there is no actual deposit of tubercles. Thus, a slow inflammation, with 
an abundant secretion of mucus, will often attack the mucous membrane 
of the nasal fossa?, or the upper portion of the bronchial tubes, and then 
pass into phthisis. These slow, obstinate inflammations, are strictly scro- 
fulous, as much so as those of the large joints — coxalgia and white swel- 
ling; and yet they exercise only an indirect influence upon phthisis. 

3. The hemorrhagic variety. In this, hemoptysis, whether preceded by 
a violent effort or not, constitutes the first symptom. 

4. There is a fourth form, which is by no means uncommon in certain 
climates, and is met with occasionally wherever the disease shows itself. 
The patient suffers, at first, not from a disease of the lungs, or from any 
tuberculous disorder, but from dyspepsia, chronic disease of the liver, or 
some other affection of the abdominal viscera, either of an acute or chronic 
nature. During the course, or at the termination of these diseases, the 
tuberculous attack commences and develops itself in the lungs, because 



714 GERHARD'S CLINICAL LECTURES. 

these organs are especially subject to tubercles from a peculiar law of the 
economy. In climates where the diseases of the abdominal viscera are 
very frequent, phthisis is thus obscure at first, because its symptoms are 
blended with those of the original disease. The same thing is true of 
dyspepsia, which often masks the early stages of phthisis, especially in 
those cases in which the patient does not labour under simple dyspepsia, 
but under that variety which is connected with a scrofulous constitution. 

But these different forms of phthisis, though differing so much in their 
origin, after a certain period present the same character; they are all at- 
tended by emaciation, cough, expectoration consisting of pus and softened 
tubercular matter, hectic fever, and all the other signs which mark the 
more advanced stage of the disease. The progress of phthisis is most 
rapid when produced by inflammation of the serous membranes, especially 
in young subjects; it is less so when preceded by bronchial inflammation. 
The hemorrhagic variety is likewise rapid in its course; the slowest of all 
is that which is constitutional and hereditary. All of these forms are liable 
to be confounded with other diseases: thus, the first may be mistaken for 
simple serous inflammation ; the second for bronchitis; the third for hemor- 
rhage arising from other causes. 

We might multiply the varieties of phthisis almost to an indefinite num- 
ber, but the preceding are the most important, and may be considered as 
the landmarks in the study of the disease ; under one or other of these 
classes, all other forms may be included. There are likewise other tuber- 
cular affections, not commencing in the lungs, and only implicating them 
secondarily; but phthisis pulmonalis is by far the most frequent form in 
which the tubercular diathesis develops itself in adults. 

I will conclude the lecture by showing you some very interesting patho- 
logical specimens, which illustrate this subject. They are the lungs and 
intestines of a subject who lately died of phthisis in its most aggravated 
form. I could only refer to the case at the last lecture; the patient, a 
young man, being then so feeble as to render it improper to bring him 
before you. The physical signs, during life, indicated the existence of a 
large cavity in the left lung: many of you have heard the cavernous, am- 
phoric, and gurgling sounds of respiration, which were extremely distinct. 
In the course of his illness, the patient also had tubercular diarrhoea. 

You will at once recognise the existence of a cavity in the upper lobe 
of the left lung, by the falling in of its parietes as I hold it up. This whole 
lobe, indeed, is converted into a mere sac, nothing of the normal structure 
remaining, except the pleura, and a thin layer of the tissue of the lungs on 
its inner face. The large size of this cavity accounts for the great distinct- 
ness of the amphoric respiration in the last stages of the disease. The 
cavity is lined by a false membrane, and contains a considerable quantity 
of muco-purulent fluid mixed with particles of tubercular matter. The 
muco-purulent matter is a secretion from the false membrane; and the con- 
tents of the cavity differ from the expectoration only, in not containing 
saliva, which is mixed with them afterwards. The sputa in this case were 
not of the nummular form, of which I showed you a specimen just now, 
for some days before the death of the patient, because the cavity was too 
large for their formation. You will notice several bands or bridles pass- 
ing from one side of the cavity to the other : these consist of blood-vessels 
which have resisted the ulceration longer than the surrounding tissue: 
sometimes, however, they are opened by this process, and hemorrhage is 



PHTHISIS PULM0NALI9. 715 

the result, which is often instantly fatal. The rest of the left lung is infil- 
trated with greyish tubercular matter to such an extent, that scarcely a trace 
of the healthy tissues can be found. The tubercles are partly softened, 
and small cavities are seen here and there : these gave rise to the gurgling 
sound of respiration. 

In the right lung, the lower lobe is in a comparatively healthy condi- 
tion. The tissue of the upper lobe is engorged with blood ; tubercular 
masses are scattered through every part of it ; they are of a yellowish- 
white colour, and no signs of softening are yet perceptible. 

In order that you may see the connection between the lesions and their 
physical signs, I will read some extracts from the notes of the case. — Nov. 
4th. Respiration throughout right side expansive and full, but a little 
harsh. Left side, cavernous respiration with distinct pectoriloquy, most 
evident near the sternum, about the second rib. — Nov. 24th. Anteriorly, 
very loose gurgling, with cavernous respiration throughout the whole of 
the left side. Puerile respiration in the right side. Posteriorly, on the 
left side, very loose mucous rhonchus, with gurgling throughout ; but there 
is a little vesicular murmur near the scapula. Respiration rude in upper 
third of right lung. — 27th. Left side, anteriorly, respiration amphoric 
above ; loose gurgling in the lower third. Posteriorly (same side), gur- 
gling and cavernous respiration in the lower half, and at the summit ; in 
the intermediate space, respiration distinctly cavernous, but mixed with 
a vesicular murmur. 

I will now examine the intestinal canal. The mesenteric glands are 
enlarged, of an irregularly rounded shape, and are entirely converted into 
tubercular matter. This condition of things, when the tuberculous de- 
posit is confined to the mesenteric glands and adjacent parts, constitutes 
the disease called tabes mesenterica. In most cases of this sort, there are 
likewise tubercles, either in the peritoneum, or the follicles of tht^intes- 
tine : here they are found in both situations. 

Large intestine. — In the colon there are some ulcers in the follicles, 
with slight inflammation of the mucous coat. Near the rectum are innu- 
merable ulcers of small size, which appear like so many distinct points, 
because they have commenced in the separate follicles. 

Small intestine. — Near the ileo-ca3cal valve are numerous ulcers, evi- 
dently commencing in the glands of Peyer. Some of these glands still 
remain, but much enlarged, and containing yellowish tubercular matter, 
which is still of a firm consistence. Here you may distinctly trace the 
changes which take place in the follicles, from the first deposition of the 
tubercular matter to its complete softening, and final discharge by ulcera- 
tion. The other viscera were not examined, on account of the short time 
which remained for us to make the examination previously to the lecture. 
There is no doubt, however, that tubercles existed in several other organs, 
particularly the bronchial glands and the spleen, which are amongst the 
most frequent seats of these deposits. 



716 V GERHARD'S CLINICAL LECTURES. 



LECTURE XII. 

Phthisis pulmonalis — Pathological characters of gangrene of the lungs. 

We have another case of phthisis pulmonalis ; some remarks may serve 
to give you some further knowledge of its history and diagnosis. The 
case before us is another example of the ordinary variety of phthisis, which 
commences gradually, and without any assignable cause. The patient is 
a printer, forty-seven years of age, formerly of intemperate habits, but 
since the commencement of the disease he has been perfectly temperate. 
Last winter a cough commenced, but so gradually that the patient is un- 
able to fix the time of its first occurrence ; during the last four months it 
has been much more severe and constant, and accompanied by hoarseness. 
There has been at no time spitting of blood ; the expectoration was at 
first mucous, afterwards muco-purulent and somewhat nummular : this 
change in the character of the expectoration took place about the time 
that the hoarseness commenced. The left side of the chest is somewhat 
contracted ; the respiration is cavernous, with distinct pectoriloquy. These 
signs show the existence of a cavity, but it seems to be rather of an indo- 
lent nature. The hoarseness in this case is owing to inflammation attack- 
ing the larynx, and causing thickening of its lining membrane, and of the 
vocal cords ; this inflammation often passes into ulceration ; it is some- 
times painful, but often there is scarcely a slight tickling felt at the part. 
I find on making pressure upon the larynx, that the patient complains of 
no pain, except just below the thyroid cartilage. This inflammation is 
the result of the irritation of the tubercular matter and other discharges 
which pass over the bronchial membrane, and it may take place at several 
different points of the respiratory passages — the larynx, the trachea, or the 
bronchi. This variety of inflammation is strictly secondary, and very dif- 
ferent from that which occurs in the early stages of phthisis, in which the 
tracheal irritation is the cause developing tubercles, and not the result of 
their softening. There is generally considerable soreness attending the 
inflammation when the phthisis is acute ; in more chronic cases it is slight, 
or altogether absent. This inflammation of the air-passages, in the cases 
of which I speak, is secondary ; in others, as I have already repeatedly 
remarked, it may precede the development of phthisis. The other symp- 
toms in the present case are of the usual kind : the skin is dry and harsh ; 
there is general emaciation, with roundness and prominence of the ends 
of the fingers ; the pulse is quick, tense, and irritated ; there are chills 
about the middle of the day, followed by fever in the afternoon, and cold 
sweats at night. The fever, therefore, has the regular paroxysmal charac- 
ter of hectic. 

You have now seen cases of several varieties of phthisis, differing in 
their origin and progress ; it is time to say something of the diagnosis of 
this affection. The diseases with which it is most liable to be confounded, 
are bronchitis, pneumonia, and pleurisy, whether of the acute or of the 
chronic form ; since phthisis, also, may be either acute or chronic. It 
may likewise be accompanied by any of these inflammations, and it be- 
comes important to distinguish such cases from those of simple inflamma- 



PHTHISIS PULMONALIS. 717 

tion. The diagnosis of tubercular disease depends both on the general 
and the local signs. The first circumstance to be attended to, is the 
general appearance of the patient. The frame is emaciated ; the skin is 
of a pale and earthy aspect ; there is a restless expression of countenance, 
indicating the working of a slow disease, and entirely different from the 
alteration of the features which attends acute disorders. The emaciation 
shows itself very early in the hands and fingers, — the ends of the latter 
retaining their fulness for some time, and appearing rounded and promi- 
nent ; the nails are likewise turned inwards. Emaciation is a sign of 
great importance in the diagnosis of phthisis and other tuberculous dis- 
eases ; particularly if you find that the patient is losing flesh, although he 
eats nearly as much as in good health. When this sign is conjoined with 
others indicative of phthisis, the diagnosis becomes almost certain. The 
earthy hue of the skin is attended by a bluish tinge of the sclerotica, which 
very often occurs in phthisis. 

We likewise observe a change in the circulation. There is a peculiar 
fever attending tubercular disease, and characterized by a quick, jerking 
pulse, the result of excessive irritation. This fever is accompanied by 
chills and sweating, —the former being at first very slight, while the latter 
is much more copious than in most other acute diseases. This peculiar 
condition of the pulse and sharp febrile excitement, are most important in 
the diagnosis of general tuberculous disease of an acute kind. It is, how- 
ever, quite as well marked when the tubercles are rapidly developed in 
the lungs, as when they are deposited at the same time in several of the 
organs. The observation of these general signs should cause us to sus- 
pect the existence of phthisis, and lead us to the examination of the local 
signs. If, upon an inquiry into the latter, we are unable to ascertain the 
existence of any other disease, we are led, by a process of exclusion, to a 
confirmation of our original suspicions. 

We also derive some important points of information from a considera- 
tion of the predisposing causes of the disease. Thus, the sex exercises 
some influence ; phthisis is rather more frequent in females. Age is a 
more important circumstance : phthisis is more frequent in young persons, 
and is rarely met with after the age of thirty-five. When it does occur 
after this period, it generally depends upon some accidental cause, as 
inflammation, &c. The course of the disease is another thing to be consi- 
dered ; phthisis is in most cases slow in its progress : the diseases with 
which it is liable to be confounded are more generally acute. 

The last and most important circumstance in the diagnosis of this dis- 
ease, is an attention to the local signs. The first of these is usually an 
uneasy sensation in the chest, very different from the pain of inflammation. 
It varies greatly as to its position, sometimes shifting from one side to the 
other, or felt under the sternum. Pain, however, may be present in the 
commencement of phthisis, when it is complicated with intercurrent 
pleurisy. The cough is constant, but rather more severe at night, or early 
in the morning, than throughout the day; it is at first short, and so insig- 
nificant as hardly to attract notice, and attended by mucous expectora- 
tion ; in the progress of the disease it becomes loose, and the expectora- 
tion is muco-purulent and nummular; in a still more advanced stage, the 
cough is very loose, — the expectoration consists of pus mixed with soft- 
ened tubercular matter, and loses its nummular character. 

The physical signs are not obvious at the commencement. The first 



718 GERHARD'S CLINICAL LECTURES. 

thing observed is generally a feebleness of respiration at the upper part of 
the lungs, which afterwards changes into rudeness ; this arises from the 
obstruction of the lung by the tuberculous deposit. We next perceive a. 
crackling sound under the clavicle, indicative of the commencement of 
softening. There is likewise a dulness on percussion at the summit of 
the lung. In the advanced stages there is gurgling, with cavernous and 
amphoric respiration, and more or less perfect pectoriloquy. 

There are certain secondary symptoms regularly occurring in phthisis. 
One of these is hectic fever; at first the fever attending tuberculous dis- 
ease is not hectic ; I have pointed out the difference in a previous lecture. 
When hectic is developed, it is recognised by the chills and sweating 
which accompany it ; the flush on the cheeks, &c. ; it is always parox- 
ysmal. The Joss of appetite, and decline of digestive power, do not 
depend upon the deposit of tubercles, but upon the fever which attends 
it; they differ in no way from the same symptoms which ordinarily ac- 
company febrile diseases. The diarrhoea of phthisis, however, often de- 
pends upon the formation of tubercles. It is intermittent, very irregular 
in its character, occurring sometimes frequently in the course of the dis- 
ease, sometimes only once or twice. Its immediate cause, in most cases, 
is the development of tubercles in the glands of Peyer, which, conse- 
quently, become inflamed and ulcerated ; but diarrhoea in phthisis may 
arise from the same causes as in other diseases ; in the latter case, its 
symptoms and progress are entirely similar. Hemorrhage is another of 
the accidental or secondary symptoms of phthisis ; the blood is either 
discharged directly from the lungs by a slight cough, or it is swallowed, 
and afterwards ejected from the stomach. If the hemorrhage be profuse, 
that is, not less than two or three ounces in a day, it is considered almost 
pathognomonic of phthisis, especially in males; in females, it is not so 
certain as a diagnostic sign, for hemorrhages from different parts of the 
body often arise from suppression of the menses, &c, and are, in fact, 
vicarious discharges ; but in men, as I observed in the last lecture, in at 
least five cases out of six, abundant haemoptysis arises from tubercular 
disease of the lungs. The fact that haemoptysis is a very important sign 
of phthisis has been long known, but Dr. Louis has rendered the profession 
a decided service, by proving that the value of the sign was even greater 
than had hitherto been believed. Many cases of this hemorrhagic variety 
of phthisis terminate in recovery ; it is, in fact, the least unfavourable form 
of the disease, and therefore the value of the symptom is sometimes un- 
derrated, because in the minds of many physicians, the word phthisis 
and death are considered as almost inseparable. This form of the disease 
is probably less fatal than others, simply because the flow of blood re- 
lieves, to some extent, the vessels of the lungs, and appears to be a 
natural safety-valve, which diminishes the tendency to the tuberculous 
secretion. 

The case of gangrene of the lungs which I showed you last week has 
since terminated fatally, and I will now present to you the results of the 
post-mortem examination. You will recollect that I then stated that the 
disease affected the lower lobe of the right lung : it rapidly extended itself, 
and the patient sank in proportion. There is, in fact, no specific treatment 
by which the disease can be arrested ; all that we can do is to support the 
system until nature accomplishes the cure, if such is her design. The pa- 
thological appearances of gangrene of the lungs are closely connected with 



GANGRENE OF THE LUNGS. 719 

and explain, the symptoms during life, viz., fetor of the breath and expec- 
toration, lividity of the countenance, and the physical signs of a cavity in 
the chest. This case occurred in consequence of the patient falling into 
the river : the gangrene probably commenced about two weeks afterwards, 
and has continued for several weeks previously to his entrance into the 
hospital: since that time it has been constantly advancing. If the pro- 
gress of the disorganization could have been checked, it is probable that 
the case would have terminated favourably, for the mischief already done 
was not necessarily fatal. You will at once perceive the excessive fetor 
of the lung, and its dark green colour over the lower lobe. As I lift it 
up, the surface of the lung sinks towards the cavity, which occupies the 
greater part of the lower lobe of the left lung. The cavity rapidly in- 
creased in size during the last days of life, as was proved by the enormous 
quantity of matter expectorated, amounting to at least a pint in the course 
of the twenty-four hours. The immediate cause of death, however, was 
dyspnoea, arising from inflammation attacking the heart. 

Pleurisy, in a greater or less degree, always attends gangrene of the 
lungs; here we have the proof of its existence, in the false membrane 
which covers the surface of the pleura. This inflammation of the pleura, 
producing false membranes, and adhesions of the lung to the ribs, tends 
to prevent the perforation of the pleura, and the discharge of the gangre- 
nous matter into the cavity of the chest. From the existence of amphoric 
respiration, perforation might have been suspected in the present instance, 
had we seen the patient only on the last day or two of life: but you now 
see that no such thing has occurred, and that the amphoric respiration was 
owing to the great size of the cavity. The lung is much softened around 
the cavity, and yields readily to the knife. The cavity is large enough 
to hold the fist: it is seated entirely in the lower lobe, having been first 
formed at its upper part: the disease very rarely attacks the upper lobe. 
By an examination of the walls of the cavity, we will be able to determine 
whether any process had commenced for the cure of the disease ; when 
this does take place, it is by means of a false membrane which is formed 
around the cavity, and secretes pus and mucus, as is shown by the cha- 
racter of the sputa. But here we see no appearance of a false membrane 
nor of pus or mucus : the cavity contains a gangrenous slough, and a quan- 
tity of the offensive matter which was so copiously expectorated during 
life. The walls are blackish, and gradually pass into the healthy lung. 
The existence of cavities formed in this way, is known by nearly the same 
physical signs as those which are observed in phthisis ; but the fetor of 
the breath and expectoration is sufficient to distinguish the two diseases, 
independently of various other circumstances. The mucous membrane of 
the bronchi is inflamed in consequence of the passage of the gangrenous 
sputa over it : in some cases this matter is swallowed, and produces severe 
diarrhoea. The upper lobe of the left lung is healthy, with the exception 
of a few miliary tubercles scattered through its summit. 

The right lung became inflamed in the progress of the case. The pleura 
is covered by a false membrane of the consistence of cellular tissue, which 
is very brightly injected. This inflammation was one of the causes of 
death. The substance of the lung is healthy, with the exception of a slight 
engorgement and induration in the centre, which probably constitute the 
first stage of gangrene, and a few 7 tubercles in the upper lobe. 

Upon examining the heart, we find traces of former pericarditis, in the 



720 GERHARD'S CLINICAL LECTURES. 

patches of lymph on the surface of the pericardium, and the serous effusion 
into its cavity. The heart is of the natural size : its muscular structure is 
in the normal condition, and its lining membrane is also nearly natural, 
but not entirely so ; there is a slight thickening in the left ventricle, and 
also of the semilunar valve of the aorta. The right side of the heart is 
frequently found perfectly healthy, though the left be greatly diseased : in 
this case we perceive merely a slight opacity of the internal membrane of 
the right ventricle. The valves of the pulmonary artery are quite healthy. 
The spleen is enlarged and softened ; this appears to depend upon the 
vitiation of the blood produced by gangrene, in the same way with the 
livid hue of the skin. The liver is fatty, and of a lighter colour than na- 
tural. This fatty degeneration in males is frequently the consequence of 
intemperate habits : it is also very common in phthisis, more particularly 
that of females. In the progress of this alteration, the cellular tissue unit- 
ing the acini becomes more developed than natural, while the acini seem 
to disappear, their places being occupied by fat. 



LECTURE XIII. 

Phthisis pulmonalis (concluded) — Cases — Treatment. 

I will to-day conclude the subject of phthisis for the present course, by 
showing you one or two cases of the disease, and saying a few words in 
relation to its treatment. I shall occupy the remainder of the hour with 
some cases of cerebral and cardiac disease, and the results of a post- 
mortem examination of an individual who recently died of phthisis compli- 
cated with serous inflammations of the heart and lungs. 

I will first present to you a case of phthisis, commencing in a different 
mode from any of which I have yet spoken. The patient was attacked 
about two years since with coxalgia, from which he has never entirely 
recovered. The treatment consisted in the use of blisters and a seton ; 
the discharge from the latter, after having continued for some time, was 
allowed to cease. About eight weeks after, he was seized with cough, 
which still continues, with other signs of phthisis ; for a few days of the 
period which has elapsed since the commencement of the cough, there 
has also been haemoptysis. The phthisis in this case evidently com- 
menced with a scrofulous disease of the hip-joint ; for in two months after 
the discharge established for the cure of the coxalgia had ceased, the 
symptoms of phthisis began, and have since progressed in the regular 
order. The scrofulous diathesis, therefore, before affecting the lungs, de- 
veloped itself externally. Cases of this sort are by no means rare ; the 
external scrofulous disease may be seated in other parts than the hip ; 
sometimes, for example, it occurs in the form of fistula in ano. An im- 
portant practical question occurs in relation to such cases : Ought we to 
endeavour to cure the external disease ? If we do, there is great danger 
that the irritation may be transferred to the lungs, and lead to the deve- 
lopment of tubercles : on the contrary, if we suffer the disease to proceed 
unmolested, the constitutional irritation arising from it may destroy the 
patient, or give rise indirectly to the formation of tubercles in the lungs, 



PHTHISIS PULMONALIS. 721 

by producing a condition of the system favourable to this result. The 
proper course would seem to be, not to check the external disease too 
suddenly, but, if possible, to subdue it by degrees. Some time ago we 
had a case here, which illustrated the effects of an opposite plan of treat- 
ment. The patient was first attacked with tubercular meningitis ; after 
recovering from that, he had fistula in ano ; this was cured, phthisis con- 
sequently supervened, and the man died. These cases are extremely 
common, and you will see many such in your practice. The case now 
before us is also one in point. The arrest of these external discharges may 
likewise give rise to other diseases, among which are diseases of the heart, 
and inflammation of the lungs; the latter in such cases being often of a 
more chronic character than in ordinary pneumonia. 

Case 2. We have here an example of phthisis occurring in old age ; 
the patient is sixty-two years old. He has been employed in one of the 
oyster-cellars of this city, — a situation, from its dampness, and also its 
darkness, extremely favourable to the development of phthisis. He has 
had cough for seven years, but it has never been severe till the com- 
mencement of the past summer. There is now well-marked cavernous 
respiration, with pectoriloquy, and other signs of cavity in the upper lobes 
of both lungs. Phthisis occurring at such an advanced age is extremely 
rare. But experience shows us that no age is>exempt from this disease. 
Tubercles are found even in the foetus, and at every period of life. They 
are most frequently met with, however, about the fifth year, and after- 
wards from the fifteenth to the twenty-fifth. Cases of phthisis, or other 
tuberculous diseases, occurring in old persons, are much more frequently 
observed in hospitals than in private practice. 

I next introduce these men, formerly patients, but now employed in the 
house, in whom cavities in the lungs have been more or less perfectly 
healed. The first is a case of phthisis, in which a cavity became cica- 
trized after it had continued to a very advanced stage, but was reproduced 
upon a second attack of the disease. The patient entered the hospital 
about three years since, with all the signs of a cavity in the right lung ; 
dulness on percussion, cavernous respiration, &c, were very well marked. 
He remained in the wards for several months, during which time his con- 
dition was constantly improving : he was then discharged, and was, to all 
appearances, nearly well, — a small cavity, however, still remained, with 
slight cough and expectoration. After he had been out of the hospital 
about five months, he had an attack of intermittent fever, which continued 
for some weeks. After he recovered from the fever, he had a second 
attack of phthisis, or, as it were, a new crop of tubercles, for which he 
was under treatment in our wards. He is again much improved, though 
still feeble. The local signs indicate a partial consolidation of the lung 
by the process of cicatrization ; thus, there is dulness on percussion, and 
a diminution of the natural vesicular respiration. These indications of a 
cicatrix exist where formerly were heard a strong cavernous respiration, 
and all the other signs of a cavity of considerable size. The cure in this 
case, then, is only partial. 

But in the case which I now present to you, there has been a complete 
restoration. The patient, in the year 1835, had an attack of gangrene of 
the lungs, which continued for several months, with very fetid expecta- 
tion, and all the other symptoms of this affection. The local signs indi- 
cated a cavity large enough to contain the fist. After a time the expec- 
47 



722 GERHARD'S CLINICAL LECTURES. 

toration became muco-purulent, — a change which indicated an arrest of 
the gangrene, and the formation of a false membrane on the surface of the 
cavity. The man, as you see, is now stout, free from dyspnoea, and in 
every respect perfectly healthy. There was no scrofulous vice in the con- 
stitution, tending to reproduce the cavity, as happened in the preceding 
case. The disease was caused by cold and intemperance. As the man 
has now been well for nearly six years, the cure may be considered com- 
plete.* 

You see, therefore, that it is possible to cure a cavity in the lungs, how- 
ever infrequent may be the occurrence of such a result, especially in phthi- 
sis, where new crops of tubercles are so liable to form. The treatment, 
in all such cases, is entirely negative ; there is, in fact, no remedy for the 
lesion. All that we can do is to palliate the symptoms, and support the 
constitution of the patient till nature, if she be so disposed, accomplishes 
the cure. Generally, the prognosis, after a cavity has been once formed, 
is altogether unfavourable ; we always look for the death of the patient, 
whether the cavity be the result of a tubercular.deposition, or of any other 
lesion. But before the cavity is formed, our chances of success are much 
greater. In hospitals, however, our prospects, in either case, are far less 
encouraging than in private practice. We are entirely unable to adopt 
those measures which are most essential to a successful issue ; we can 
only employ medicinal remedies; in relation to food, clothing, air, exer- 
cise, &c, the means at our command are necessarily very limited and 
imperfect. In private practice, on the contrary, we are enabled more 
successfully to combat the general disease, by changing, as far as possi- 
ble, the whole constitution of our patients ; for this purpose, we direct a 
change of scenes and of climate by travelling, which is our principal re- 
liance in such cases. 

In the treatment of phthisis, you will find that there is great practical 
importance in the classification of the disease into several varieties, which 
I have called your attention to in preceding lectures. The inflammatory 
variety may frequently be arrested in the earlier stages by the ordinary 
antiphlogistic means which we employ in cases of simple inflammation. 
In that variety which commences slowly and gradually, on the contrary, 
we derive little or no aid from this plan of treatment. The treatment of 
phthisis, therefore, must be as various as the different forms of the disease. 
In the ordinary slow cases, we must attempt to change, as it were, the 
whole being and nature of our patient, in the same manner as we do with 
regard to the mental constitution in the treatment of insanity. By thus 
producing a change in the constitution, we endeavour to cause the ex- 
pulsion of the tubercular vice. For the details, I must refer you to the 
different treatises which have been written on the disease. 

It is unfortunate that the treatment of phthisispropershouldbe so limited, 
that is, as to the strictly curative treatment. If it be inflammatory, it is 
more immediately within the power of medicine, and a removal of the 
local inflammation, which is acting as a continual irritant upon the con- 
stitution, bringing about at last decided phthisis, is our first object, and 
then the patient will often pass little by little into perfect health, or he will 
remain in a feeble condition, which requires a change of air, a long voy- 
age, or some other constitutional renovation, to remove the remains of the 
disorder. But if these patients be improperly treated, and suffered to 
* This patient is stili perfectly well, 1848. 



PNEUMONIA. 723 

remain suffering from chronic inflammation, or if they are exhausted by 
what is termed very vigorous treatment, they may readily pass into phthi- 
sis. This is especially the case as regards chronic pleurisy: a suitable 
antiphlogistic treatment is necessary, but an eye must always be kept to 
the state of the patient's general health, and the strongest efforts should 
be made to keep up the strength and aid the constitution in throwing off 
the disease, if already developing itself, or in acquiring that vigour which 
is opposed to tuberculous disease. In such cases a mercurial treatment 
is admissible, and I believe that the safest mode in many cases would be 
to mercurialize rapidly, as recommended by Drs. Graves and O'Bierne, 
were it not for the different susceptibility of patients to the action of mer- 
cury, which must render this mode of treatment at times injurious. It is 
better, therefore, on the whole, to give mercury in more minute doses, 
and to discontinue it as soon as a constitutional impression is made. It is 
impossible, however, to exercise too much caution as to the use of mer- 
cury in individuals attacked or threatened with phthisis, and from rnv ex- 
perience in its use I would limit it to the very beginning of the disease, 
when associated with chronic pleurisy, or perhaps pneumonia : for there 
is a tuberculous inflammation of the lung which is slow to resolve itself. 

As to the treatment of the disease, properly speaking, it is so well laid 
down in different treatises upon the subject, that I must restrict my re- 
marks upon it to my lectures on the diseases of the chest, where the sub- 
ject is necessarily enlarged upon. 



LECTURE XIV. 

Pneumonia — Jaundice — Tubercular meningitis — Pathology of laryngitis and laryngeal 

phthisis. 

We have lately had several patients convalescent from acute diseases, 
especially inflammatory affections of the lungs. I shall conclude the 
lecture with a few remarks on the tubercular affection of the membranes 
of the brain, so common among children, and with the demonstration of 
some pathological specimens illustrating the history of laryngitis. 

Case 1. — In the two preceding lectures I spoke to you of a man la- 
bouring under an acute disease of the lungs, the severity of which ren- 
dered it improper to remove him from the ward. He is now before you 
in a state of convalescence. This man entered the hospital about a month 
since, at which time he presented the signs of pneumonia, complicated 
with an incipient tubercular affection — the latter impressing certain modifi- 
cations upon the character of the former. Under the treatment which was 
adopted, the patient at first did very well ; but suddenly grew much 
worse, in consequence of the supervention of pleurisy, followed by copious 
effusion. The distress produced by this complication added to that imme- 
diately consequent upon the proper affection of the lungs, and brought 
the patient to the brink of the grave. The dyspnoea and prostration of 
the system were extreme. In this condition of things, a mild, depletive 
plan was pursued ; the great depression of the recuperative powers cf the 
patient put all active measures of the kind cut of the question. A single 
cup was, therefore, applied, and repeated according to the necessity 



724 GERHARD'S CLINICAL LECTURES. 

of the case ; at the same time the patient was put upon the use of 
mercury. 

This treatment was soon followed by an improvement in the aspect of the 
case, which, however, was not very decided, until the action of the mercury 
was made manifest by the occurrence of slight ptyalism. From that 
time (seven or eight days since), the patient has been steadily improving. 
But convalescence, in a case like the present, is never so rapid as it is in 
simple pneumonia. This is owing partly to the tubercular diathesis of 
the patient ; in part, also, to the abundance of the pleuritic effusion, which 
always requires a certain time for its removal by absorption, more parti- 
cularly when it co-exists with pneumonia or tubercles. The case is one 
of considerable interest, as illustrating the advantages of very moderate 
depletion, and of the judicious employment of mercury in certain forms 
of acute pulmonary disease. In relation to the latter remedy, I have re- 
peatedly urged upon your attention, that we employ it in acute affections, 
not for the purpose of salivating our patients, but of producing its specific 
constitutional influence. Its effect upon the mouth is the mark of this 
influence, or of the saturation of the system with mercury; after the 
slightest possible redness of the gums is produced, the influence of the 
remedy cannot be rendered more complete and decided, no matter how 
copiously it be given. 

Case 2. — This is an instance of pneumonia so mild as hardly to require 
any treatment. The patient is a man aged forty-nine ; he is of robust 
frame, and has led an active life, having been for some years a soldier in 
the Peninsula; he has generally enjoyed good health. He has lately 
been employed in cutting ice. On the 19th he was taken ill ; the first 
sign of the disorder was a chill. This was followed by cough, but no 
pain in the chest ; the expectoration has been viscid from the first, but 
has never been coloured with blood ; at no time has the patient been con- 
fined to bed. On the 25th he entered the hospital, — and, on examining 
his chest, the physical signs of pneumonia were detected. The following 
pectoral mixture was ordered : — - 

R. Ext. Hyoscyami, gr. viij. 

Syrup Polyg. Senegae, 3]. 

Mucilag. Acaciae, ^v. 
Ft. Mist. 

211th. The hot infusion of eupatorium was ordered. Under the action 
of this remedy, the disease passed off by a copious diaphoresis : the 
patient is still sweating. He may now be considered as convalescent. 
It would appear, therefore, that only eight days elapsed from the com- 
mencement to the crisis of the disease. This seems to be in contradiction 
to a rule which I laid down in a preceding lecture, viz., that the usual 
duration of pneumonia is from fourteen to twenty-one days. 'But it is to 
be remarked that although the general signs indicate the declension of the 
disease, the local signs still exist; there are yet manifest some dulness on 
percussion, and crepitant rhonchus. By the time that these have disap- 
peared, the case will probably be brought nearly within the minimum 
which I have stated. This is the usual course of mild cases of pneumonia. 

In cases like the present, no active treatment, and little, indeed, of any 
kind is requisite. Hot diaphoretic and nauseating drinks, are the best 
possible remedies. Such instances of mild attacks are less frequent in 



PJfEUMONIA. 725 

pneumonia than in most other diseases, and the expectant and palliative 
treatment just mentioned, is rarely worthy of confidence. But when such 
cases do occur, a more active treatment only puts the patient to inconve- 
nience, without resulting in adequate benefit. I wish particularly to in- 
culcate this principle, that, when a disease is tending to a favourable ter- 
mination, all measures of an active kind should be dispensed with; it 
should be a matter of conscience with the physician not to harass the 
patient with unnecessary applications. An opposite course of practice 
tends, in no small degree, to throw discredit on the profession. This 
hurtful officiousness arises not from any defect or error in the plan of 
instruction in our schools, but from an idea which is so apt to be enter- 
tained by every student from the commencement of his studies, viz., that 
every disease is recognised by certain signs, and requires for its cure a 
certain set of remedies. So that whenever the symptoms indicate the 
existence of inflammation, bleeding, purgation, and revulsion at once 
suggest themselves to his mind. It requires experience to teach him that 
there are, in fact, many cases of inflammation, and still more of continued 
fevers, which require no such violent measures. 

Case 3. — In this case we have pursued a plan of treatment precisely the 
reverse of that adopted in the preceding one. Very free bleeding an 1 
other depletory measures have been resorted to, but not with a correspond- 
ing amelioration of the symptoms, because they were not practised until 
the disease had made considerable progress. The patient, Shepherd, was 
seized with pneumonia on the 8th inst. ; he was admitted into the hospital 
on the 18th ; so that ten days had elapsed before any attack upon the dis- 
ease was made. The treatment was commenced by the abstraction of 
twenty ounces of blood from the arm ; this was followed by cups to the 
side, which were repeated three times ; the patient was also placed upon 
the use of the infus. eupatorii. Notwithstanding these active measures, 
the disease continued to advance, with very slight modification of the symp- 
toms. The combination of opium, digitalis, and calomel, of which I have 
already so often spoken, was then ordered, mainly with the view of ob- 
taining the antiphlogistic action of the mercury. Two days after his en- 
trance, the patient was taken with singultus, which came on at particular 
periods in the days, and continued for an hour or two at each attack. Hic- 
cough is a symptom of grave import in inflammatory affections, and is in- 
jurious in itself, inasmuch as it serves to exhaust the strength of the pa- 
tient. It seems not to depend directly on the inflammation, but on a sym- 
pathetic irritation of the nerves of the diaphragm. It is a symptom which 
is more frequently met with in some seasons than in others ; during the 
past year we have not had many instances of it. As it was not quieted 
by the treatment already adopted, assafoetida was ordered with this view ; 
this failing, the oil of amber was ordered, in doses of six drops, repeated 
according to circumstances. Under this treatment, the singultus gradually 
subsided, and the disease took a favourable turn. 

At the last lecture I remarked to you that the duration of this case would 
probably not be shortened by the active practice which had been pursued, 
and the result has verified the remark. Bleeding, however copious, will 
not cut short an inflammatory disease, unless practised soon after its inva- 
sion ; a few hours may carry the affection beyond the point at which de- 
pletion may cause it to abort. After it has passed this point, bleeding, 
though it does not arrest the course of the disease, is still of use, by pal- 



726 GERHARD'S CLINICAL LECTURES. 

liating its inconveniences, and diminishing its tendency to run into fatal 
disorganizations. 

Little change was perceptible in the condition of the patient until the 
25th, when he was somewhat better. On the 26th he appeared to be in 
a state of convalescence. On the 27th this favourable change was still 
more evident. The face was pale and sunken ; I have already stated that 
this subsidence of the features after the fulness and flushing produced by 
inflammatory excitement, is one of the best signs of convalescence. The 
pulse had fallen from ninety-six to eighty ; it was soft and tremulous. The 
respiration had also fallen from thirty to twenty in the minute. No doubt 
therefore could exist as to the fact of the patient's convalescence ; the 
simultaneous subsidence of the respiration and the pulse rendered it per- 
fectly certain. On the contrary, if the pulse had become slower, while the 
respiration retained its frequency, we should have concluded that the pa- 
tient was in a much worse condition. 

The duration of this attack of pneumonia was nineteen days, which is 
within the average which I stated in my remarks upon Case 1. Pneumo- 
nia, in fact, has a natural duration, and one principal object to be aimed 
at in its treatment, after the disease is established, is to prevent accidental 
circumstances from interfering with the natural tendency of the disease to 
terminate at a certain period. 

Jaundice. — The patient, aged 45, entered the hospital on the 23d insfc. 
He had always enjoyed good health until last summer, when he had an 
attack of dysentery. On the 22d, after exposure to wet and cold, he was 
seized with cough, and the same evening he had a chill, attended with 
pain at the xiphoid cartilage. On the 23d he was jaundiced ; the skin, 
conjunctiva, and urine, were of a deep yellow, and every object appeared 
to his sight to be of the same colour ; the skin was moderately warm ; there 
was no headache, but pain and tenderness in the right hypochondrium, 
which obliged the patient to lie on the left side ; expectoration was slight ; 
pulse moderately full. Venesection, cupping over the region of the liver, 
and a diaphoretic infusion, were ordered. 

24th. Patient more jaundiced ; pain had extended to epigastrium ; slight 
signs of bronchitis observed. Cups repeated, and an infusion of senna, 
with sulphate of magnesia, ordered. 

26/A. Patient now complained of headache, and vertigo, depression of 
mind, &c. Bleeding repeated. 

From this time the symptoms rapidly abated, and few remains of the 
disorder are now perceptible. The skin is only slightly coloured on the 
breast; the vision has become natural; the skin is moist: it has never 
been hot, however, at any time in the progress of the case. 

The most prominent symptom of this case, besides the alteration in the 
colour of the skin, was the tenderness in the right hypochondriac and epi- 
gastric regions, accompanied by dulness on percussion. It was inferred 
from these signs that the liver was congested, and slightly inflamed. In- 
flammation of the liver is by no means a common occurrence in the winter 
season. The prevailing inflammatory diseases are those of the lungs, heart, 
and fibrous tissues of the extremities ; the abdominal viscera are more 
rarely affected. But this man's previous history affords a very sufficient 
reason for the occurrence of hepatitis in his case. Last summer he had 
an attack of dysentery ; now, a severe dysentery hardly ever passes through 
its course without involving the liver in a greater or less degree. There 



JAUNDICE. 727 

is, therefore, a strong presumption, that this man's liver was at that time 
affected ; it was naturally left in a condition favourable to the return of 
disease, upon the occurrence of the usual causes. This circumstance de- 
termined the deleterious impression of cold to the liver rather than to the 
lungs. 

Jaundice depends on a great variety of causes. When acute, as in 
the present case, and dependent on congestion and slight inflammation 
of the liver, it is in general easily cured. It yielded in this case to bleeding, 
cupping over the liver, and saline purgatives. Mercury was not employed 
at all in the treatment : the only character in which it could have been used 
with propriety was that of an evacuant, — and in this case it seemed to offer 
no particular advantages over saline and other purgatives. You will re- 
collect that in the numerous instances recently brought to your notice in 
which this article was employed it was not as a purgative, but as an anti- 
phlogistic remedy in certain stages of inflammatory affections. 

Headache was an important symptom in this case, and its occurrence 
induced us to repeat the bleeding. In all cases of jaundice, indeed, cere- 
bral symptoms demand particular attention : for it is usually in consequence 
of the supervention of cerebral affections that this disease proves fatal. 
The cause of this complication is the suppressign of the biliary secretion, 
the elements of which being retained in the blood, act like a poison upon 
the system, especially on the brain. In like manner, urea, if retained in 
the blood, proves deleterious. In fact, all diseases of the liver or kidneys, 
attended with suppression of their secretions, are followed by coma, and 
other signs of cerebral oppression, in consequence of which they terminate 
fatally. It is in this way that the granular affection of the kidneys, called 
"Bright's disease, " often proves fatal. When the cerebral symptoms arc 
active, the proper treatment is general and local bleeding, cold applica- 
tions, &c. But in jaundice it is often impossible to remove them until the 
bile is eliminated from the blood ; this is effected slowly, and by a prooes> 
of nature. If the symptoms are attended with much depression of the 
vital energies, depletion becomes improper, and we have to rely on other 
means, the most effectual of which experience proves to be sinapisms an J 
blisters. 

At the last lecture I introduced a man labouring under acute laryngitis, 
upon whom an operation was performed in your presence, but without 
success. This case was one of acute, grafted on chronic laryngitis. 
The affection was originally acute (having commenced about a year ago), 
but became chronic, and continued so till ten days before the patient's 
entrance ; it then became acute, and the symptoms were strongly marked 
at the time, of his entrance. It was likewise observed that the lungs were 
affected, — but in what way, the signs were too obscure to enable us pre- 
cisely to determine. The lungs were pervious to the air, so that there 
was little dulness on percussion ; but the respiration was feeble through- 
out the right side, and some crepitus was distinguished below. It was 
hence inferred that the lung was congested, but nothing else could be 
made out with any certainty : as you will presently see, these signs were 
owing to the development of miliary, tubercular granulations, in great 
abundance, with congestion of the surrounding tissues. The operation of 
laryngotomy, performed by Dr. Gibson, produced some relief for the mo- 
ment ; but the dyspnoea returned every time the artificial opening became 



728 GERHARD'S CLINICAL LECTURES. 

obstructed, and not more than half an hour elapsed before the man died 
of suffocation. The operation was resorted to as the only chance of pro- 
longing life ; but even if it had been more successful for the time, it could 
not, in the end, have saved the patient — for an immense number of grey- 
ish, semi-transparent, tubercular granulations, had filled the upper and a 
part of the lower lobe of the right lung, and the upper and a part of the 
lower lobe of the left. But, had the condition of the patient been such 
as to allow a full examination and positive diagnosis, the operation would 
still have been justifiable, as the only means of securing to the .patient a 
few more hours or days of life. 

The immediate cause of the intense dyspnoea under which the patient 
laboured, was edema of the larynx, and inflammation of the trachea and 
bronchia?. The former offered a very great obstacle to the passage of the 
air through the rima glottidis — while the trachea and bronchi were lined by 
a layer of very viscid mucus, which interposed a further obstacle to its 
entrance into the lungs. The matter lining the air-passages was not, pro- 
perly speaking, a false membrane, but it was so dense that it could be 
detached in shreds of considerable length. There was likewise an ulcera- 
tion of the lining membrane of the larynx, between the posterior extre- 
mities of the vocal cords, and extending to the cricoid cartilage. 

This case is one of interest, inasmuch as it illustrates the connection 
between laryngitis and phthisis. Laryngitis sometimes occurs as the pri- 
mary, sometimes as the secondary disease. The latter was the case in a 
patient who lately died in the female wards ; during the progress of a 
tubercular affection, she was attacked with laryngitis, which was indi- 
cated by the ordinary symptoms, dyspnoea and aphonia. When laryngitis 
occurs as the original affection, it may continue for years, attended with 
more or less cough, hoarseness, and dyspnoea, but without any indications 
of disease in the pulmonary tissue. At last ulceration occurs ; at this 
point, in a very large proportion of cases, tubercles are developed in the 
lungs. In this variety of phthisis the tubercles are generally greyish, 
semi-transparent granules, of small size, and uniformly diffused through 
the lung. Consequently, phthisis following laryngitis, is one of the most 
intractable varieties of the disease. In all cases where the affection of the 
larynx has advanced to ulceration, we apprehend the supervention of 
phthisis. Almost the only variety forming an exception to the rule, is 
that form of ulceration of cartilages and of the mucous membrane which 
occurs in secondary syphilis. But it is easy to discriminate such cases 
by the general condition of the patient, the history- of the affection, &c. 
Besides, ulceration of the larynx consequent on syphilis almost always 
extends rapidly into the cartilages. The prognosis of laryngitis is never 
grave until ulceration has occurred : if there be merely thickening of the 
membrane, a cure may frequently be effected ; but if ulceration takes 
place, this result can hardly be hoped for. 

If the dyspnoea should be excessive, and threaten suffocation, an opera- 
tion for its relief is the only resource. There are several different methods 
of performing such an operation. Dr. Gibson, in the case which we have 
been considering, preferred laryngotomy. This is usually done by making 
a transverse incision through the crico-thyroid membrane. In France, 
the operation for croup is often performed, and at the present day surgeons 
generally are in favour of tracheotomy. In this operation, a longitudinal 
incision is made into the trachea, which is kept open for the passage of 



LARYNGITIS. 729 

air, either by means of a canula, or of a blunt hook applied to each edge 
of the incision. This operation is preferred to laryngotoray ; inasmuch 
as it admits of a more extensive opening, through which the false mem- 
brane may be pulled away. 

I now show you the larynx and trachea of the man who died after the 
operation of laryngotomy was performed. The lining membrane of the 
larynx was at first highly injected ; but by maceration in water, the blood 
has been almost entirely washed out. However, you can still perceive 
the edematous state of the glottis. This edema was produced by the 
effusion of serum under the mucous membrane, in the same manner that 
it is effused from the surface of inflamed serous membranes. The mucous 
membrane is softened ; at the posterior part of the larynx is a large ulcer, 
and many smaller one's are scattered over the remaining portions of the 
larynx, as well as the upper part of the trachea. The mucous membrane 
of the trachea, like that of the larynx, was highly injected. The epiglottis 
is slightly thickened at its lower part. In the crico-thyroid membrane, you 
see the opening made by the operation ; it is not quite so large, in fact, 
as the natural opening of the glottis ; it therefore easily became obstructed 
by the viscid secretions which filled up the air-passages. 

The upper lobe of the left lung, and all the lobes of the right one, con- 
tain an immense number of small, grey, semi-transparent granulations. 
In the right lung, they are so numerous as to have almost obliterated its 
vesicular structure. A tubercular deposition of this kind never occurs, 
except in acute phthisis. The right lung is likewise congested, particu- 
larly at the lower part, over which the crepitant rhonchus was heard 
during life. At the summit of the lung is a cicatrized cavity, containing 
a mass of calcareous matter. The surrounding parenchyma is puckered 
and contracted by the cicatrix, and the adjacent pleura is covered by 
adhesions. These appearances indicate the former existence of tubercles ; 
these were probably deposited at the same time the chronic laryngitis 
occurred, and were removed by the absorption of their animal matter, the 
calcareous portion remaining behind and constituting the white masses 
which you here see. 

Here are the lungs of another patient, who entered the hospital in the 
last stage of phthisis, and died within forty-eight hours. I show them to 
you for the purpose of contrasting the early, with the latter stages of the 
affection. At the summit of one lung is a large cavity, and in that of the 
opposite one are numerous small granulations, of recent origin. 

When the tubercular granulations are deposited in great numbers through 
the pulmonary tissue, the disease is almost always acute, and, in fact, is iden- 
tical with what is often called the u galloping consumption." The termina- 
tion of this variety, which is almost always fatal, occurs in two ways : in the 
one the patient dies of dyspnoea, and you find, as in the present case, the 
lungs excessively congested, through all that portion of them in which the 
granulations are deposited. The death then actually takes place by suf- 
focation. I have seen some examples of it ; one of the first was some 
years ago, when I was a resident pupil of this hospital. A black, who 
had been labouring under the disease for some time, with much dyspnoea, 
called to us one day while making the visit, that he was strangling, and 
died almost immediately ; the lungs were excessively congested, and 
almost stuffed with these granulations. 

In most cases, the disease passes on to softening at the summit, at least 



730 GERHARD'S CLINICAL LECTURES. 

of the lungs, while the rest of the tissue is engorged and filled with the 
granulations. In these cases there is high fever, sweating, and generally 
intense dyspnoea. The cough, however, may be very slight. You will 
find the respiration generally feeble, and the chest less sonorous than 
usual. 

There lately occurred a disease of the brain, which I am accidentally 
prevented from showing you, and which was interesting as an illustration 
of an affection of which I may perhaps speak more fully at a future time, 
— tubercular diseases of the membranes of the brain. The case was that 
of an adult. On opening the cranium, tubercular granulations were found 
beneath the membranes, both on the superior surface and base of the brain ; 
in the intervals left by them, the membranes were injected, and covered 
with lymph. The affection probably followed the development of tuber- 
cles in the lungs ; the examination was not extended to these organs. 
The deposition of tubercles under the membranes of the brain was followed 
by acute inflammation, which resulted in effusion, and softening of the 
cerebral substance. This was indicated by rigidity and paralysis of the 
extremities ; muttering delirium ; subsultus tendinum ; contraction, and 
afterwards dilatation of the pupils; distortion of the mouths The occur- 
rence of symptoms of meningitis in the course of tubercular phthisis, may 
be considered sufficiently certain evidence of the development of the affec- 
tion of which I am speaking. In children it is indicated by the signs 
commonly described as belonging to acute hydrocephalus. This disease, 
so called, which is frequent from the age of two years up to puberty, is 
neither more nor less than tubercular meningitis ; the inflammation is 
usually attended with effusion into the ventricles or on the surface of the 
brain, and from this circumstance the ordinary appellation of the disease 
is derived. But the effusion is altogether an accidental matter ; and so 
is the softening which sometimes occurs. It is the tubercular deposit, and 
the concomitant inflammation, which constitute the essential characteris- 
tics. 



LECTURE XV. 

Typhus and typhoid fever — Symptoms — Treatment. 

In the works of many writers on the continued fevers of Great Britain and 
Ireland, you will find that the only distinction admitted by them, as to 
the nature of these diseases, is that of the degree of severity of the symp- 
toms. Thence the common division into typhus mitior and gravior ; terms 
indicative only of the greater or less intensity of these disorders. In 
France no efficient attempt was made to trace the distinctive characters 
of the different affections classed under the name typhoid until the year 
1806, when the work of Petit and Serres was published. These writers 
found that in the forms, such as they witnessed at Paris, there was a con- 
stant anatomical lesion seated in the abdomen and occupying the follicles 
of the ileum, especially the agglomerated patches, or, as they are often 
called, the glands of Peyer, seated near the ileo-caecal valve, the mesen- 
teric glands, and the spleen. These alterations were inflammatory, the 
affection of the glands of Peyer being attended with redness, thickening, 



TYPHUS AND TYPHOID FEVER. 731 

and often passing into ulceration, while the mesenteric glands were en- 
larged, reddened, and softened, and the spleen was enlarged and soft- 
ened. The evidence of inflammation was indeed perfect, except as re- 
garded the spleen, of which the lesion might be regarded as dependent 
either upon inflammatory softening, or as the result of an alteration of the 
fluids of the body. 

The after-investigations of Dr. Louis proved this matter much more 
conclusively. In his excellent work upon typhoid fever he has shown 
that the disease is uniform, and accompanied by a regularly-developed 
series of symptoms, not occurring in a confused manner, but forming to- 
gether a well-characterized whole. It was this uniformity which enabled 
him to designate the disease in such a manner that there is now no diffi- 
culty in separating the cases of it which are met with from those of the 
different affections classed under the vaguely used terms — typhus and 
typhoid fever. 

In Great Britain, and still more frequently in Ireland, another disease, 
which is endemic in those countries, is called typhus fever, and resembles 
in many particulars the typhoid fever described by Dr. Louis. It differs 
from it in its symptoms, but especially in its mode of extension and in its 
anatomical characters. The latter are not fixed and regular ; on the con- 
trary, the organs are diseased in so many different degrees, that observa- 
tion proves that there is no one uniform anatomical character, unless it be 
the condition of the blood, which is evidently altered in many cases, and 
probably so in others, in which the demonstrative proof is wanting. The 
lesion of the glands of Peyer is not met with in this disorder, unless it be 
in a straggling case of typhoid fever, classed among the cases of typhus ; 
or in a complicated case, which is extremely rare, but I believe occasion- 
ally met with. 

The deductions of Dr. Louis, as to the anatomical lesions of typhoid 
fever, have not therefore lost any of their value ; they still remain true as 
applied to the disease described by him ; but they are not applicable to 
the English typhus, or, as Dr. Graves calls it, the maculated fever. In 
order to prevent confusion in these terms, I have for some years past used 
the term typhoid fever, as applicable to the fever described by Petit and 
Serres, Louis, and even by Rcederer and Wagler, and I restrict the term 
typhus to the disease described by the British writers, and not attended 
by the intestinal lesion. This distinction is gradually passing into com- 
mon use in the United States. At one time I was disposed to adopt the 
term typhus mitior as applicable to typhoid fever, but I found that there 
were many cases and various epidemics of typhus fever in which the 
symptoms of the disease were extremely light and the mortality inconsi- 
derable, but still the leading characters all remained, and the identity in 
the symptoms of the disorder was in nowise weakened. The terms mitior 
and gravior may, therefore, very properly be used to designate merely the 
degrees of severity of the affection, and not to distinguish two different 
forms of disease ; the former is happily the more frequent form ; the lat- 
ter appears only in a few places, or in close confined ships and hospitals, 
where a number of men are crowded together. 

The symptoms of typhoid fever are not all found in every case ; that 
is, some one or more of those which are considered leading symptoms 
may be wanting, but the group of those which remain is in every case, or 
nearly so, quite large enough to identify the disorder. For convenience, 



732 GERHARD'S CLINICAL LECTURES. 

you may divide them into distinct groups ; first, those of the cerebral and 
nervous system ; secondly, of the skin ; thirdly, of the abdominal viscera ; 
and, lastly, of the thoracic organs. 

Those of the first series are, loss of strength and prostration, which 
occurs very early in this disease, singing in the ears, vertigo, and not 
unfrequently epistaxis. The pains in the head and limbs are not so vio- 
lent as in the remittent or intermittent fevers. There is more frequently 
chilliness than a regularly defined chill. These are usually the earliest 
symptoms, followed after some days by slight diarrhoea and other-abdomi- 
nal disturbance. The brain symptoms increase slowly, the patient be- 
comes dull and stupid ; if the disease be violent, he may become coma- 
tose. Delirium is not invariable, although it is rarely quite wanting ; but 
if the disease be mild, it shows itself only at night, and for a short time. 
In severe cases the delirium is violent, and if this be complicated with 
meningitis, the patient may fall into the wildest ravings ; it is in general 
much more mild and low, or muttering. In fatal cases coma almost al- 
ways precedes death. 

In typhus we have a different succession of symptoms, and a difference 
in their development. From the very first attack of the disease the stupor 
is the most prominent symptom ; sometimes the intelligence of the patient 
is in some degree preserved, although he seems to be in a dreamy, stupid 
condition, almost inattentive to surrounding objects, but still capable of 
answering correctly and continuously when his attention is excited. The 
recollection of the patient after the attack is extremely confused, and the 
stupor resembles in many respects a state of somnambulism. Besides the 
stupor, headache, dizziness, and tinnitus, are all amongst the early symp- 
toms of typhus, but the strength is much less broken down than in typhoid 
fever. If the disease advances, the patient becomes comatose at a much 
earlier period than in typhoid fever, and generally dies, if the case be fatal, 
of the brain symptoms. Delirium is a very frequent symptom ; indeed 
there are few cases in which it is totally absent ; it is almost always of the 
still, muttering kind, except when complicated with inflammatory action 
of the brain. The cerebral symptoms of the two forms of fever differ less 
from each other than many other groups of symptoms, but there is, in the 
majority of cases, a greater difference in the character of the symptoms 
than is easily described ; especially as regards the stupor, which is much 
deeper and more disproportioned to the other symptoms in typhus than in 
typhoid fever. 

The external symptoms of the two diseases vary ; you have seen that 
both are attended with a cutaneous exanthema, but in typhus this is 
general, extending over the whole body ; in typhoid fever it is limited to 
the anterior part of the trunk, that is, the abdomen and thorax, rarely 
reaching as far as the thighs. The typhous eruption consists of a measle- 
like rash, slightly elevated, of a light red at first, but after the second day, 
or in severe and malignant cases, from the first, of a darker tint. The 
papulse are rounded and vary in size, from an almost imperceptible point 
to the breadth of nearly a line. The rash is not, strictly speaking, pete- 
chial, that is, if the term petechias be confined to ecchymoses of blood in 
the derm, but it is frequently called by this term, and in the papers which 
I have published in 1837 the word is used in this sense. The rash gra- 
dually subsides after four or five days, but it is sometimes visible for ten, 
twelve, or even fourteen days. It appears usually about the third day of 



TYPHUS AND TYPHOID FEVER. 733 

the fever. There is no other eruption which is peculiar to typhus ; suda- 
mina are, however, occasionally met with about the groins, and other 
parts where the skin is thin, especially during the hot weather. The 
measle-like eruption is evidently an exanthema, and very similar to the 
papular eruption of measles in its development and progress ; and, from 
its constant occurrence, Dr. Graves calls the disease the maculated typhus. 
The eruption of typhoid fever is papular, but the spots are rather larger, 
about a line in length, elliptical, more elevated, few in number, often not 
exceeding six or eight, and rarely more than thirty ; they appear a little 
later than those of typhus, but last about the same time. The sudamina 
are much more frequent than those of typhous fever, and often appear in 
two different crops, one early in the disease, and another just before con- 
valescence. 

It is not yet settled whether any form of continued fever is met with 
which cannot be referred to one of these classes : I have myself seen none. 
But we must remember that some of the symptoms of typhus occur in 
many diseases in which the blood is more or less altered, such as phlebi- 
tis, asthenic pneumonia, &c, and thus may be confounded with these 
diseases, just as certain stages of remittent fever are often called by the 
same name, and regarded as mere varieties of typhus. But there is not 
in any of these cases the complete series of symptoms, although some 
isolated ones may be met with, in diseases which resemble in some re- 
spects these fevers, but are without the characteristic eruptions. 

The symptoms connected with other organs vary in the two fevers. 
The abdominal symptoms of typhoid fever are, diarrhoea, which is a fre- 
quent though not invariable symptom, flatulence with tympanitic disten- 
sion, pains in the abdomen, sometimes at the epigastrium, at others in 
the iliac fossa. In typhus no one of these symptoms is found, except as 
a rare and accidental complication. The thirst and anorexia are common 
to the two diseases ; but the former symptom is generally more marked 
in typhus, the latter in typhoid fever. 

The thoracic symptoms are but moderate in mild cases of these fevers. 
In the typhoid the bronchial mucous membrane is congested, especially 
in the smaller tubes. The congestion produces a slight sibilant rhonchus, 
and may of course pass into bronchitis or pneumonia of a severe character. 
In typhus the lungs are also congested, but it is in a different way. The 
posterior part along the spine seems full of blood ; causing at times a 
mucous rhonchus, but preventing in a great degree the air from passing 
into the smaller tubes. This condition of the lungs seems more depend- 
ent upon the state of the blood than that of the mucous membrane, pro- 
perly speaking, which is only secondarily involved. 

The action of the heart is not violent in either disease ; on the contrary 
it is often enfeebled, especially in typhus, in which the loss of power of 
the heart is one of the strongest indications for a stimulating practice. 
The pulse is more frequent in typhus than in typhoid fever. The capil- 
lary circulation is more or less altered in both diseases ; hence the skin is 
dull and of a dusky tint, and at the face is often of a deep red colour, as 
if excessively congested, and the blood circulates slowly through the ves- 
sels, especially in typhus. The capillary vessels of the conjunctiva are 
injected in typhus, and full of blood, which circulates rather slowly through 
them ; but in typhoid fever we have rather ia bright eye than the dull, 
heavy, bloodshot one of the former disease. The medical physiognomy 



734 GERHARD'S CLINICAL LECTURES. 

of the patient, which is mainly dependent upon the capillary circulation, 
is one of the best diagnostic signs of the two diseases, but it is very diffi- 
cult to describe. 

There are some other circumstances which are of interest in relation to 
this matter. One is, that typhus fever spares no age, is more severe 
amongst the aged and those in middle life than the young, and generally 
prevails as an epidemic, extending itself by contagion, or direct propaga- 
tion, from an infected individual, or still more frequently from a mass of 
infected individuals, to others. Typhoid fever, on the other hand, rarely 
assumes this infectious character, and is rarely epidemic, probably it is 
scarcely infectious, except when prevailing epidemically. I never met 
with a case of the genuine typhus in this country before the year 1836, 
but typhoid fever is always a common sporadic disease, especially in the 
northern parts of the United States. I have seen both varieties in newly- 
arrived passengers from emigrant ships, but rarely in the same ship. The 
typhus attacked a much larger number of patients than the typhoid, and 
was often increased in severity in direct proportion to the number attacked. 
In some of these ships the disease w T as evidently propagated from one indi- 
vidual, who contrived to embark while labouring under the, disease, and 
then those sleeping in the same berth with him were the first attacked. 
The origin of the fever was clearly transatlantic in all such cases, and in 
fact it was merely the Irish typhus, carried over to America by Irish emi- 
grants, and sometimes propagating itself afterwards. 

The treatment of mild cases of typhus is extremely simple : regarding 
it, as I do, as a self-limited disease, which necessarily tends to recovery 
unless arrested by some accident, I content myself with the simplest mea- 
sures, acting as it were in the direction of the disorder, but not opposing 
any obstacle to the natural working of disease which tends to relieve itself. 

At first I give the patient a dose of oil, which generally relieves his 
giddiness, and direct a mustard foot-bath at night, sometimes twice a-day, 
and give him either simple lemonade, a neutral mixture, or what is still 
better the solution of the acetate of ammonia. Should the face become 
flushed, a few cups may be applied to the nucha and behind the ears ; 
but if the patient merely complain of great giddiness and deafness, With- 
out increase of the vascular action about the brain, dry cups are nearly as 
useful as the scarified. The oil maybe repeated during the course of the 
disease if the patient be constipated. No other treatment is necessary 
during the mild form of the disorder ; indeed any treatment can scarcely 
be said to be necessary ; but it is useful, and diminishes the severity of 
the symptoms, and I am convinced, from long and careful observation of 
this disease, that even therapeutic means cannot be made more active 
without injury to the patient. 

At the close of the fever, however mild it may be, there is always an 
incomplete collapse ; the patient may then take wine-whey and a more 
nutritious diet ; but I agree fully with Dr. Graves, that in any stage of 
typhous fever, a regimen of almost starvation is rarely justifiable. 

In more severe cases of the disease decided treatment is necessary ; we 
must guard against the complications, the accidental symptoms, and sup- 
port the strength of the patient when recovering. The lectures of Dr. 
Graves are full of important practical illustrations of these points, which 
I am not able to enlarge upon without going far beyond the limits of this 
lecture. 



TYPEIUS AND TYPHOID FEVER. 735 

My object as to the treatment is to impress upon you the leading truth, 
that typhus is a real exanthematous disease, and has a natural course to 
run. No one should dream of interfering with this course when it is pass- 
ing through its regular and ordinary stages. 

The treatment of typhoid fever is not yet well settled. Like typhus it 
has a natural course, and about the same average duration (twenty to 
twenty-one days), but it is not yet certain whether the treatment should 
be, as in the mild cases of typhus, purely negative and defensive, or more 
active and aggressive. My own experience leans towards the former 
conclusion : I am strongly inclined to think that in mild cases the physi- 
cian should interfere as little as possible, should restrict himself to laxa- 
tives, abstain from stimulants, resort from these to cups, either dry or 
scarified, to the nucha, now and then, but rarely to blisters. Towards 
the close of the disease, a mild alterative, consisting of small doses of 
mercurials, such as calomel or blue pill with ipecacuanha, hastens the 
cleaning of the tongue, and favours the convalescence. Tonics and mild 
stimulants are at times necessary after the termination of slight cases. 

The purgative treatment of typhoid fever has attracted much notice of 
late years. I mean what may be termed the purely purgative treatment, 
consisting in the repeated administration of saline laxatives, so as to keep 
the bowels in a soluble state during the course of the disease. The re- 
sults of the treatment are certainly extremely favourable, and it is very 
possible that it may be the best mode of treating the disease, which differs 
from typhus, not only in the general symptoms, but in the very different 
condition of the alimentary canal. 

The treatment of severe cases of typhoid fever is necessarily modified 
by the symptoms, and you must study carefully the cases of the disease 
which you see, and bear in mind the pathology and general course of the 
disease, and then you will at least rarely commit any important errors. 
You w T ill find that, on the whole, the disease requires a less stimulating 
practice than typhus ; it is more inflammatory in its primary as well as its 
secondary lesions. For details, I must refer you to the work of Dr. Louis, 
and to the excellent memoir published by Dr. James Jackson, of Boston. 

In your practice you may rarely meet with typhus, but you will be sure 
to see cases of typhoid fever, and you should consider the two diseases 
as distinct, but as allied together more or less closely ; — each one of them 
offering numerous sub-varieties, as different from each other as a mild 
case of scarlatina is from a malignant one. The advantages which I en- 
joyed of carefully studying the pathological anatomy, and the symptoms 
of the two fevers, enabled me to place the question of their identity upon 
more settled scientific points than had yet been done ; for by reference 
to the writings, both of British and continental physicians, you will find 
that the confusion is but lately dissipated. It is true that, after the ob- 
servations w r hich formed the basis of the paper which I published in 1837, 
were collected, but before their publication, Dr. Lombard, of Geneva, 
who was of course familiar with typhoid fever, stated in the Dublin Jour- 
nal that the two diseases were different ; the same remark I remember to 
have heard Professor Andral make on the authority of Dr. Alison ; and it 
was obvious to many persons that the description of Dr. Louis did not 
apply to the British typhus, but the points of resemblance and of differ- 
ence were not settled, that is, they were not scientifically demonstrated. 

The views which I have given you are gradually receiving the sanction 



736 GERHARD'S CLINICAL LECTURES. 

of physicians. How far experience may modify them I do not know ; but 
it is probable that it will only add some new facts to those which we 
possess, without impairing their authority. The seeming discrepancy of 
previous statements may be perfectly reconciled with the facts, as is amply 
proved by Dr. Valleix, in the memoirs which he published on this subject 
in the Archives de Medecine, about the beginning of the year 1840. In 
the last edition of his work, Dr. Louis has taken up the same subject, and 
I am gratified to find that, far from retaining any doubts as to the patho- 
logy of these diseases, he fully admits that they are allied, but not iden- 
tical.* 



NOTES ON TYPHUS AND TYPHOID FEVER IN THE YEAR 

1848. 

The subject of typhus and typhoid fever has received great attention in 
the United States, within a few years, from the large number of cases of 
typhus fever introduced in emigrant passenger ships from Great Britain. 
The disease has been in some of our large cities very extensively diffused, 
but chiefly amongst emigrants recently arrived, and a small number of 
native citizens who were accidentally brought into close connection with 
them. In all the large seaports, many thousand cases have occurred ; and 
even in cities remote from the seaboard, the disease has extended itself, 
although it was mainly limited to the recently-arrived emigrants and to a 
few others who were brought into immediate contact with them. The 
large number of cases which have thus been freshly introduced directly 
from the British islands, have furnished us with the most convenient 
opportunities possible for the study of the disease, and to a great degree 
have diminished the difficulties which have hitherto belonged to this 
subject. 

The principal question to determine was, whether this disease was 
identical with the typhoid fever which is always found more or less dif- 
fused in different parts of the world, or was in reality a distinct affection. 
My attention had already been given to this subject from being called 
upon to treat an epidemic fever which occurred at the Blockley Hos- 
pital (Philadelphia) in the year 1836 ; and, from much study of the disease, 
I was led to conclude that it was altogether a different disorder from the 
typhoid fever which we had been accustomed to see here and at Paris, 
and that it did not differ apparently from the typhoid fever of the British 
islands. In this opinion my colleague, Dr. Pennock, who was also per- 
fectly conversant with the fever of Paris, agreed with me, and his observa- 
tions fully confirmed my own conclusions as to this matter. I published 
■ an account of this epidemic in the American Journal of Medical Science, 
in February and August, 1837, and I there stated the conclusions to 
which I had arrived, and noted particularly the difference in symptoms 

* The observations of British physicians confirm the views which I gave as to the pathology 
of these fevers. One of the latest writers goes over the same grounds as myself, and refers 
frequently to the memoirs of Dr. Valleix, without citing the papers which were the subject of 
his analysis; nor does he ever allude to them, except to give a garbled quotation from Dr. 
Valleix, — an apology, the author says, for citing American instead of British writers upon a 
fever which was especially prevalent in Great Britain. The observations in question, however 
wanting in scientific fairness, confirm the general statements as to the symptoms and causes of 
the continued fevers. 



TYPHUS AND TYPHOID FEVER. 737 

and lesions between this disease and the typhoid fever of Paris. Since 
that time, there has been an abundant opportunity of examining the sub- 
ject more closely, from the continuance of this epidemic influence, which 
did not disappear at the Blockley Hospital for some years after its ap- 
pearance; while from the opportunities which have occurred of studying the 
symptoms and lesions of the cases introduced into this country directly 
from the British islands, I have been able to compare the two epidemics 
of fever with each other, as well as with the typhoid fever which is always 
more or less present in this country. From these abundant opportunities, 
I have been enabled to extend my observations on this subject, and to a 
great extent have arrived at results more definite than those which I had 
already reached, because they were formed on a larger scale of observa- 
tion, and extended to the diseases brought in masses from Europe, as well 
as to those which originated in the United States. 

From these extended sources of observation, I have arrived at the fol- 
lowing conclusions as to the symptoms and character of these fevers. 

The typhoid fever of France is constantly met with in the United 
States, although it varies very much as to its relative frequency and seve- 
rity. It is not confined to any particular season of the year, but occurs 
at every period. I have, however, found that it is rather more frequent 
in the autumn than at any other season. In the United States it is more 
frequent at the North than the South, where it becomes quite rare, espe- 
cially in those parts of the country at which yellow fever or other autumnal 
fevers are very prevalent. In the New England States, it is more frequent 
than in any other portion of the country, and frequently appears there as 
a severe epidemic, extending itself to different parts of the country. 
When these epidemics occur, the disease becomes more certainly conta- 
gious than at other times, and does not follow the ordinary law relative 
to the freedom from the disease which generally prevails amongst persons 
who have reached the middle periods of life. The typhoid fever is, then, 
the regular continued fever of the United States, as well as of the continent 
of Europe. 

The typhus fever of Great Britain appeared in the United States under 
circumstances very favourable for its study, inasmuch as it was with us 
almost a new disease — certainly a new one so far as regards the rigid 
examination of the distinctive symptoms. Although 1 call the disease the 
typhus fever of Britain, I do so, not because the disease is absolutely con- 
fined to the British islands, but because it is there much more rife than in 
any other country, and prevails there as the most constant form of fever. 
The epidemic of 1836, at Philadelphia, was evidently not of foreign 
origin, but originated in the city of Philadelphia, at a season of the year 
when very few emigrants arrive in this country, and amongst a class of 
persons who have very little connection with them. Still the disease is 
on the whole an infrequent one in the United States, while the typhoid 
fever is always to be met with in greater or less number of cases, just as 
it is in France, and presenting the same peculiar symptoms. 

The proper typhus fever being the constant epidemic of the British 
islands, and vastly more frequent than the typhoid fever which is met 
with there, just as it is in France, has, to a certain extent, given a strong 
inclination to British physicians to regard it as the only, or at least the 
principal form of fever, while the typhoid form was looked upon as a 
more ameliorated variety of it, scarcely possessing the characteristic symp- 
48 



738 GERHARD'S CLINICAL LECTURES. 

toms of a peculiar disease, but constituting little else than a new modifica- 
tion or variety of the regular typhus. With this view of the subject I 
am, however, far from agreeing; the forms of disease are on the whole 
quite distinct, and do not often offer much difficulty in the diagnosis, 
while the pathological lesions are equally characteristic. We always find 
in typhoid fever of the United States, the lesions of the glands of Peyer, 
of the mesenteric glands, and of the spleen, which are considered in 
France as the pathognomonic lesions of the disease ; while in typhus fever 
we always find the follicles of the small intestines and the mesenteric 
glands perfectly healthy, the spleen is often softened, but not usually to 
as great a degree as in the typhoid fever. The only lesion which to a 
certain extent seems to be common to the two diseases, is an altered con- 
dition of the blood ; what the nature of this alteration is, and how similar 
it may be in the two diseases, cannot be certainly shown, but it is evidently 
the immediate cause of the alteration of the spleen, and it probably gives rise 
to the various symptoms which are to a certain extent common to the two 
affections. I have never met with a case of typhus fever, or with a single 
exception a case (see American Journal of Medical Science, Feb., 1837), 
which I supposed at the time to be typhus fever, in which the lesion of 
the glands of Peyer was found. Cases undoubtedly are met with, although 
rarely, by physicians, in which a disease regarded as typhus fever during 
life was found to present the lesion of the glands of Peyer supposed to be 
characteristic of typhoid fever, but I cannot avoid thinking that in these 
cases one disease may have been mistaken for another, or that some of the 
proper symptoms of typhus fever may, during an epidemic, have been 
extended to cases of typhoid fever, so as to modify them to a certain 
degree. Of these cases 1 cannot, however, speak from my personal 
knowledge ; but it seems to me that this explanation is one which more 
easily reconciles the apparent cause of difficulty in diagnosis, than any 
other one. 

Typhus fever, which had appeared at Philadelphia in 1836, did not 
entirely cease for several years, but the cases were few in number and 
almost limited to the poorest classes of the population. In the year 1847, 
however, this city, like most of the seaports in the United States, received 
large numbers of Irish emigrants, who brought the disease with them. 
Some of these died at sea or recovered before reaching port, others were 
taken to the different quarantine establishments, and a large number, who 
landed in good health, were attacked by the disease soon afterwards. 
From these patients, a certain number of those who were thrown into im- 
mediate contact with them, contracted the disease. In the year 1847, a 
number of patients were admitted with typhus into the Pennsylvania Hos- 
pital : of these, nineteen cases entered the hospital labouring under typhus 
fever during my term of service. Of these patients, eleven were seamen, 
belonging to passenger ships from the British islands, on board of which 
were passengers labouring under typhus fever. Four were themselves 
emigrant passengers belonging to ships in which fever prevailed, but who 
were not taken with it until after they had passed quarantine. Of these 
nineteen, many of whom offered the disease in a severe form, seventeen 
recovered. Two died, both of whom were Italian seamen, belonging to 
the same ship. Four were patients who contracted the disease in Phila- 
delphia from other patients affected with it. 

Patients labouring under this disease are not commonly admitted into 



TYPHUS AND TYPHOID FEVER. 739 

the hospital ; the fever belonging to the number of those diseases which 
are contagious, at least under certain circumstances. With strict atten- 
tion to ventilation, the contagious character of the disease is so much 
diminished, that it is not considered necessary to entirely exclude those 
labouring under it, although the number of patients was not as large as it 
would have been if it had not been thought desirable to restrict them to a 
small number. All seamen, however, labouring under the disease were 
admitted without hesitation, and besides them, a considerable number of 
other patients, who were not selected on account of the disease having 
assumed a grave or slight character. 

The patients who died with the disease both belonged to the same ship, 
from which we received in all four seamen, all labouring under the dis- 
ease in a very severe form. Of the seamen who recovered, one of them 
was English, the other a German. I shall now give a sketch of the two 
cases which proved fatal. 

An Italian seaman, P , aged 27 years, entered Sept. 20th, 1847. 

Arrived in ship Berlin a day or two before from Liverpool. The disease 
appeared in the ship a few days after leaving Liverpool. A number of 
cases had occurred before her arrival in port, of which several died at 
sea, and many others were removed to the quarantine station. Patient 
speaks very little English, so that no anterior history could be obtained 
from him ; it was known, however, that he had been ill but a few days 
before coming into the hospital. Present condition : skin hot, face 
flushed, eyes injected, much stupor, but no obvious delirium, eruption 
of minute red points, not elevated, covering the whole body, disappearing 
partially under pressure, conformation of abdomen natural, not sensitive 
on pressure, bowels not open since admission, tongue dry, coated, not 
very red, pulse 96, soft. Spts. raindereri, hot pediluvia, cold to head, 
sponging body, arrow-root. 

Sept. 22d. Feels better, rather less stupor, face flushed, intelligence 
perfect, pulse 92, soft, easily compressed, eruption of a darker tint, no 
tympanitis, no sudamina, spleen slightly enlarged, tongue dry, coated, 
moderately red. Treatment continued. 

Sept. 24th. Skin hot, pulse 108, tongue red at tip, less coated, with 
some tendency to moisture, eruption of a deeper tint, does not disappear 
on pressure, bowels open once since yesterday, subsultus moderate. Con- 
tinued treatment. Ice constantly allowed to patient ; swallows it with 
great avidity. 

Sept. 25th. Skin comparatively cool, sweating, pulse 112, tongue red 
and dry, eruption still visible, bowels open once or twice since yesterday, 
bladder distended with urine, which is drawn off by catheter, stupor, but 
no delirium. Treatment continued, with addition of ,sviii. wine in 24 
hours, essence of beef, carb. ammon. gr. v. every hour. 

Sept. 27th. Stupor increased yesterday, is now very heavy, cannot be 
aroused, unable to answer questions, pulse about 100, very irregular, ex- 
cessively feeble. Treatment directed yesterday was continued, and 3V1. 
brandy given, and blisters applied to extremities. Died at 4 o'clock in 
the afternoon. 

Post-mortem, 20 hours after death, was made in presence of Dr. Bartlett, 
of Transylvania University. The examination was not extended to all 
the viscera, from want of time. Viscera of abdomen and thorax were, 
however, carefully examined. Small intestines were found perfectly 



740 GERHARD'S CLINICAL LECTURES. 

healthy throughout their whole extent, presenting neither the slightest 
trace of inflammation nor ulceration. Glands of Peyer and Brunner 
were but moderately developed, without the slightest trace of inflamma- 
tion or ulceration. Mucous membrane generally was also perfectly nor- 
mal. Mesenteric glands natural in color and consistence. Stomach and 
large intestine by accident, unfortunately, were not examined, but no doubt 
were in a perfectly normal condition. Spleen enlarged to length of seven 
or eight inches, rather more soft than natural, engorged with reddish blood. 
Liver engorged with blood, perfectly natural consistence. Lungs con- 
gested with blood in posterior part. Mucous membrane of bronchial 
tubes slightly reddened. Heart rather soft in consistence, containing 
very little coagula. 

This case, which was unequivocally one of typhus fever, terminated 
about the tenth or twelfth day after its appearance. At the admission of 
the patient, the usual symptoms of the disease were developed, but the 
disorder did not assume the character of extreme danger until about 30 
hours before its termination. The examination after death, although 
incomplete in some respects, from accidental causes, afforded the same 
absence of positive lesions as is usually the case in pathological researches 
into this disease : the patient not apparently dying from any local inflam- 
mation, but, from the severe impression of the disorder upon his whole 
body, was perhaps less able to resist it than the natives of colder coun- 
tries. The treatment was nearly similar to that used in the large number 
of cases that recovered. 

P. T , age 29, Italian seaman, admitted September 29th, shipmate 

of last patient, in Berlin. Taken ill on 24th, a week after arriving in 
port, with pains, cephalalgia, &c, had no chill. Condition, 29th and 
30th : stupor, memory impaired, face moderately flushed, eruption of red 
points appearing over surface of skin, tongue red at tip — coated poste- 
riorly, abdomen retracted — no sensibility on pressure, skin pungent, heat, 
pulse 100, easily compressed, bowels opened by Seidlitz powder on admis- 
sion, neutral mixture, ice, pediluvia. Diet, arrow-root, &c. 

Oct. 1st. Skin less hot, pulse 100, face flushed, eruption of spots abun- 
dant on abdomen and thorax, no sudamina, no cephalalgia, no delirium 
at night, much stupor. Treatment continued, with addition of wine §iv., 
in whey daily, beef-tea. 

Oct. 2d. Muttering delirium last night, intelligence now good, subsultus 
frequent, pulse 96, feeble, skin but moderately hot, eruption still abun- 
dant, tongue moist, coated, bowels open twice in twenty-four hours. 
Quinine, gr. i., every two hours, in addition to former treatment. Cold 
applications to head if stupor should increase, and carb. ammon., gr. v., 
every hour or two. 

Oct. 3d. Symptoms continued as they had been, carb. ammonias, gr. v., 
every two hours was given, with wine, ^x., brandy, §vi., daily. Blis- 
ters to back of neck and extremities. 

Oct. 4th. Eyes injected, suffused, face flushed, much stupor, delirium 
at night, subsultus, abundant eruption over skin, tongue protruded with 
difficulty, very dry, coated, pulse 83, feeble ; bowels also open this morn- 
ing after taking Seidlitz powders. Continue treatment. Wine, brandy, 
carb. ammon., gr. v., every hour. Quinine. 

Oct. 5th. Skin was cooler, face slightly flushed, eruption less distinct, 
slight subsultus, less stupor, but delirium at night, pulse 554, tongue dry, 



TYPHU8 AND TYPHOID FEVER. 741 

covered with a dark coat, protruded more readily than before. Treat- 
ment continued. 

Oct. 6th. Pulse very feeble, 85, still delirium at night, now very stu- 
pid, subsultus, with rigidity of muscles of arm, eruption still very abun- 
dant over the whole body. Wine increased to §xii., carb. ammon. gr. 
x. every hour; other treatment continued. 

Oct. 7th. Skin cool, pulse 85, intelligence better, medicine taken more 
readily, less subsultus, less lividity of face, urine sometimes drawn off with 
catheter, at other times passed involuntarily in bed. Treatment continued. 

Oct. 8th. Skin less warm, face less flushed, less stupor, tongue more 
moist, eruption very faint. Continued treatment, reducing carb. ammon. 
to gr. v. every hour. 

Oct. 9th. Skin nearly natural temperature, pulse 84, countenance more 
natural, intelligence clearer, but still stupor, subsultus subsided, tongue 
dry, red, brownish at centre, protruded with less difficulty. 

Oct. 11. Still stupid, pulse 84, skin cool, tongue dry, brownish at cen- 
tre, bowels open two or three times in last twenty-four hours, not involunta- 
ry. Continue treatment, increasing carb. ammon. to gr. v. every half-hour. 

Oct. 12th. Occasional delirium, tongue red and dry, bowels open seve- 
ral times last night and this morning ; discharges involuntary, pulse 92, 
feeble, was attacked yesterday with nausea and vomiting, it still con- 
tinues without being checked by blisters to the epigastrium. Ice-water, 
brandy and water, ess. beef, in teaspoonful doses throughout the day. 

Oct. 13th. Emaciation greater, complete apyrexia, no vomiting since 
last night. Continue treatment. 

Oct. 14th. Vomited this morning after drinking a quantity of water 
which was not allowed him ; no return of vomiting afterwards. 

Oct. 16th. Heavy, stupid, tongue red, dry, brownish at centre, pulse 
100, feeble. Treatment continued, arrow- root allowed in addition. 

Oct. 19th. Intelligence perfect, no return of vomiting. Treatment 
continued. 

Oct. 20th. Sloughs have formed on sacrum and haunches, blisters on 
legs are suppurating, great feebleness. Treatment continued. 

Oct. 21st. Erysipelas developed over left eye within last two days, 
patient extremely feeble. Egg and wine, arrow-root. 

Died at half-past 4 o'clock, p.m. * 

Examination of body twenty-four hours after death. 

Exterior. — Considerable emaciation, erysipelatous redness around right 
eye, scattered ulcerations on legs, extending vertically six inches in length. 
The ulcerations are in process of healing, are from three to six inches in- 
tervening, portions of inflamed skin intervening. Inflammations on sacrum 
and contiguous portion of Glutei muscles, with ulcerations ; some twelve 
to eighteen lines in diameter. Integuments on each side of vertebral 
column, from spine of scapula downwards, of a dark red or livid hue, 
with occasional small ulcerations towards lower part. 

Thorax.— Heart, pale, soft ; contained small coagula. Lungs mode- 
rately engorged, at lower portion posteriorly. Bronchial mucous mem- 
brane perfectly healthy. Some old adhesions on either side of chest. 

Abdomen — Stomach. — Minute vessels moderately injected with bright 
arterial blood, mucous membrane of natural thickness and consistence. 
Small intestines moderately distended, containing thin yellowish fluid, not 
injected, consistence normal, glands of Peyer and Brunnerperfectly healthy. 
Large intestines healthy throughout the whole extent, neither injected nor 



742 GERHARD'S CLINICAL LECTURES. 

ulcerated. Liver pale, firm, structure not altered. Gall-bladder dis- 
tended with dark-coloured bile. Spleen slightly softened, normal in 
size and colour. Kidneys rather pale, perfectly healthy in appearance. 

This case terminated fatally on the twenty-seventh day. The disease 
passed through its usual course, the fever abating decidedly, eruption dis- 
appearing entirely, and the intelligence of the patient having nearly returned 
to its natural condition ; the first symptom of a decidedly unpleasant kind 
was the nausea and vomiting, which rendered it impossible to continue 
the use of stimulants in as large doses as had been previously used. The 
strength of patient however improved, and it became possible to resume 
the stimulants in some degree, but he was already so debilitated that they 
failed to produce the wished-for effect, and the patient seemed to die at 
last of exhaustion ; the ulcerations which had formed along the back and 
on the legs were probably a powerful cause favouring the fatal termination. 

The lesions, as is usual in this fever, were almost totally negative, that 
is, no organ presented traces of evident inflammation ; and we are, there- 
fore, as is usually the case in typhus fever, obliged to look for the causes of 
death in the alteration of the blood, and the accompanying disorders of 
the brain and nervous system. This result coincides precisely with the 
lesions of the last case, as well as with those observed in a patient who 
died under the care of Dr. Pepper a few days before I took charge of the 
wards. The disease is therefore perfectly identical, so far as the absence 
of lesions is concerned, with the epidemic of typhus fever which occurred 
in Philadelphia in the year 1836, and occasionally reappeared for Several 
years afterwards : this epidemic I described in the American Journal for 
February, 1837, and gave a short sketch of it in the preceding lecture 
in the year 1842. In several successive years, 1838, 1839, and 1840, 
I met with a number of cases of the same disease in recently-arrived emi- 
grants, in all of whom the disease was identical, both in symptoms and 
lesions, with the epidemic of 1836-7. 

During the years 1838-9, a number of cases of typhoid fever were also 
observed among the recently-arrived emigrants : some of these cases, I 
believe, came from vessels in which the greater number of passengers 
suffered with the typhus now described. The distinctive characters of 
the two diseases were, in almost every case, perfectly well marked, so 
that it was almost always as easy to distinguish the two diseases by the 
symptoms during life, as to point out the difference in lesions after death. 
At the Philadelphia Hospital, typhus fever prevailed this year on an ex- 
tensive scale, but like the cases we have described, it was confined to 
emigrants and those who contracted the disease from them. In that in- 
stitution I have learned from Drs. Buchanan and Thomson, who were 
lately residents there, that the bodies which they examined were also free 
from any characteristic lesion. 

In the New York Hospital, however, I understood from some of the 
gentlemen in attendance this summer, that they sometimes met with the 
lesions of the glands of Peyer, similar to those usually observed in typhoid 
fever. I must confess I cannot reconcile this singular discrepancy of re- 
sults, except by supposing that in some rare cases the contagious principle 
of typhus fever may have been applied to patients who were about to be 
taken ill with typhoid fever^ and that in this way this seeming inconsistency 
should have appeared. So far as my own observation however extends, 
in a number of examinations which must now considerably exceed one 
hundred, I have never met with a case in which the symptoms of typhus 



TYPHUS AND TYPHOID FEVER. 743 

fever were followed by the lesions of the glands of Peyer, peculiar to the 
typhoid disease, if we except a single case mentioned in the paper pub- 
lished in 1837, which occurred when the disease was still new to us in 
Philadelphia, and in which there was really an error of diagnosis. 

The symptoms of neither of the cases which proved fatal offered any- 
thing peculiar. Although stimulants were used more profusely in this 
case than in the first one, the benefit resulting from them was by no means 
permanent ; still, had the patient retained his food and medicines so that 
we could have given them in as large doses as seemed to be absolutely 
necessary, there is little doubt but that he would have recovered. 

W. R.,aetat. 35 years, English seaman, shipmate of the two last patients, 
was admitted 20th September. Was perfectly well when he left Lazaretto, 
where ship was detained ten days. Taken ill on 17th with chilliness, 
cephalalgia, pains in back and extremities. Took no medicine except a 
purge of calomel and jalap before admission. When admitted was ordered 
spts. mendereri, ^ss. every two hours, cold to head, sponging. 

Sept. 21st. Present condition : intelligence perfect now, but is con- 
scious of being delirious at times, dull, heavy, but face not flushed, eyes 
nearly natural, skin hot on head and central parts of body, cool on extre- 
mities, pulse 84, soft, tongue dry, coated, red at tip, no sensibility of the 
abdomen, no tympanitis, no eruption ; bowels open three times this morn- 
ing, not disturbed yesterday. Continued prescriptions, adding pediluvia 
twice a-day. 

Sept. 22d. Skin hot, pulse 88, less flushed, slight traces of the eruption 
on abdomen ; treatment continued. 

Sept. 24th. Eruption more distinct, extending over whole surface, 
pulse 84 — intermitting one beat in every 8 or 9, tongue dry, covered with 
yellowish brown coat ; treatment continued. 

Sept. 25th. Mind at times bewildered, but not positively delirious, 
abdomen retracted, not sensitive to pressure, pulse 90 : treatment con- 
tinued : ice given him to chew. 

Sept. 26th. W T ine,Svi., given in whey, during day, with essence of beef. 

Sept. 27th. Stupor increased yesterday, still continues, pulse 80, feeble. 
Discontinued acet. ammoniae. Continued wine, ess. beef: sinapisms 
applied to legs. 

Sept. 28th. Countenance better, pulse 66, tongue disposed to clean at 
tip and edges, skin cool, eruption nearly disappeared, few sudamina pre- 
sent, abdomen rather retracted, not sensitive on pressure, appetite not 
returning ; continue wine, ess. beef, adding quinia, gr. i., every two hours. 

Sept. 29th. Complained only of weakness, pulse 52, feeble, bowels 
once open last night, once this morning, tongue cleaning. Increase wine 
to ^viii. Continue ess. beef, quinia. Brandy, 3 ij. daily, egg beaten up 
with wine in addition. Carb. ammonia?, gr. v., wine given every two 
hours yesterday afternoon ; discontinued to-day. 

Sept. 30th. Pulse 48, feeble, increase brandy to 3iv. daily, carb. am- 
nion., gr. v. every hour during day. Continued former treatment. 

Oct. 2d. Pulse 44, tongue cleaning, carb. ammonias to be given occa- 
sionally only ; other treatment continued. 

Oct. 5th. Pulse risen to 48, skin of natural temperature, eruption dis- 
appeared on 1st. 

Oct. 6th. Pulse 52. From this time he continued to improve. Brandy 
discontinued on 11th ; wine diminished to gvi. daily ; quinia and ess. beef 
continued. Eggs, chicken, &c. On 14th left his bed. On 27th, after 



744 GERHARD'S CLINICAL LECTURES. 

being up several days, pulse was examined and found to beat 64 in a 
minute. Was discharged on 30th.* 

This patient was ill about 20 days until his convalescence was fully 
established. His symptoms, like those of the last patients, consisted in 
extreme prostration, stupor, with delirium, characteristic eruption on body; 
the pulse was feeble and not very frequent. At the conclusion of the 
disease, the pulse became exceedingly slow, and was also quite irregular. 
Treatment consisted in the abundant use of stimulants, which he bore 
perfectly well, and which he still required after the entire cessation of the 
fever. The eruption, as in most of the cases during the present epidemic, 
extended over the whole body, but was less abundant than it usually was 
during the epidemic of 1836-7. 

The cases which I have just given will serve as abundant proof of the 
perfect identity of the form of typhus described by me as having occur- 
red in Philadelphia in 1836, with the British variety. The same symp- 
toms, the same absence of distinct lesions, and the same necessity for 
using a stimulating treatment at the conclusion of almost every case, and 
in the earlier periods of many of them. The treatment is always perfectly 
simple : the patient should be placed in a well-ventilated room, in which 
but few persons should be allowed to remain. He should have wine at 
an early period of the disease, with light animal broths and nutritious but 
digestible articles of diet, such as sago, arrow-root, and the like, at a much 
earlier period than in most febrile diseases. Brandy is sometimes neces- 
sary, especially for patients who are accustomed to the use of spirits when in 
health, but it should be allowed only when the patient is so much exhaust- 
ed, that wine would seem to be an insufficient stimulant. The proper 
medicinal articles are of comparatively little avail in checking the course of 
the disease, although they are very important in relieving the temporary 
causes of danger into which a patient may fall. In moderate cases of the 
disease, I merely keep the patient's bowels open, and give the ordinary 
neutral mixture, or the spirit of mindererus, with cold sponging to the 
head and sometimes over the whole surface, either with simple water or 
vinegar and water, or with a solution of chlorine. When there is ex- 
treme congestion towards the brain in the early periods of the disease, 
blood-letting may be borne without depression by the patient ; but I almost 
always prefer the application of a few cups to the back of the neck : this is 
a safe and quite as effectual a mode of taking away blood as venesection. 
Dry-cupping will often quiet the restlessness of the patient, and is there- 
fore a valuable remedy. In more severe cases, we are obliged to use 
nearly the same means : wine may be given more freely, sometimes cam- 
phor is a useful adjuvant, opiates are generally totally inadmissible, but 
sometimes, when there is much restlessness and great jactitation, a very 
small dose of morphia will quiet it better than any other remedy. Blis- 
ters are not so objectionable as in typhoid fever, but as they cause much 
irritation and restlessness, they should not be often used ; sometimes, if 
they are applied to the back of the neck, they diminish the delirium and 
do good. 

With this treatment the mortality in typhus fever will in general be 
small, but it is a disease which will give very variable results, depending 
as much on the character of the epidemic as upon the condition of the 
patients when they are attacked. 

* The notes of these cases were taken from my dictation by a very intelligent young phy- 
sician, Dr. Hutchinson of Missouri, then a member of the class. 



INDEX. 



Aberdeen Infirmary, Report of Fever in, by 

Dr. Kilgour, 140 
Abscess of the heart, case of, 344 
Abuse of mercury in syphilis, 320 
Acetate of lead in tympanitis, 79 

in Asiatic cholera, 590 
Acidity of the stomach in indigestion, 573 
Acute inflammation of the heart, 644 
Affections of the bones in syphilis, 296 
Ague, hysterical, 601 
Ague-cake, 599 

treatment of, 601 
Air in the alimentary canal, use of, 77 
Albuminous urine in dropsy, 605 

opinion on the na- 
ture of, 459 
Alison, professor, views on the pathology of 
phthisis, 247 
opinion as to the time of life in 
which phthisis supervenes, 
249 
Alvine discharges, peculiarities of, 622 
Amaurosis, 585 

Anatomical characters of continued fever, 59 
character of the yellow fever at 
Gibraltar, 183 
Andral, professor, opinion as to the period of 
life in which phthisis mo9t fre- 
quently occurs, 254 
on the development of tubercle, 
521 
Animal chemistry, Liebig's strictures on, 44 
Annals of the surgical department of the Ge- 
neral Hospital at Hamburgh (Fricke's), 
extract from, 280 
Anus, excoriation of, in scarlatina, 447 
Apjohn, Dr., analysis of St. John Long's 

liniment, 212 
Apoplexy, or cerebral hemorrhage, 674-679 

pulmonary, remarkable case of, 232 
Aretaeus, description of enlargement of the 

spleen, 489 
Arklow, Dr. Wright's account of scarlatina 

in, 439 
Armagh, immunity from scarlatina, 437 
Armstrong's, Dr., theory of fever, 58 
Arnott, Dr., reference to his elements of phy- 
sics, 583 
Arsenic in psoriasis, 575 
Arsenical solution, caution necessary in pre- 
scribing it, 575 



Arthritis, obstinate case of, 562 

with jaundice and urticaria, 553 

Arthurstown, Dr. Long's letter on scarlatina 
in, 442 

Asiatic cholera, use of acetate of lead and 
opium in, 590 

Asthma, case of, 211 

Atmospheric electricity, remarks on, by Ed. 
Clarke, 368 

Auchenlech, Dr., letter on cholera, 593 

Autenrieth, Dr., account of the state of medi- 
cine in Great Britain, 422 

Baglivi's opinion quoted, 209 

Barker and Cheyne, report on fever, quoted, 

68 
Barker, Dr., allusion to his paper on quinine, 5 1 
Barrett, Dr. Joseph, case of narcotism from 

ofKum, 73 
Bed-sores in fever, and their treatment, 127 
Bell's paralysis, occurring in jaundice, 399 
Berlin, treatment of syphilis in the hospital of, 

310 
Bewley, Dr., letter on scarlatina, 441 
Billard on tubercles in the lungs of foetuses, 

249 
Brunonian school, allusion to, 422 
Blake's experiments, 57 
Blakiston, Dr., on influenza, 558 
Blisters, advantages of, when judiciously used, 
99 
constitutional irritation arising from, 
389 
Blood in melaena, characters of, 623 

the forces by which it is circulated, 399 
Bones, affections of in syphilis, 296 
Bonorden, Dr., publications on syphilis, 311 
Bountiful, a certain Lady, her practice in 

fever, 65 
Boxwell, Dr., letter on scarlatina, 439 
Boyer's views on purulent ophthalmia quoted, 

274 
Brain, scrofulous inflammation of, 93 
Bright's disease of the kidney, 460 

kidney, remarks on, 605 
British teacher of medicine, great responsibility 

attached to his office, 49 
Bronchitis, 712 

on the rales produced by, 203 
chronic, use of chalybeates and eme- 
tics in, 210 



746 



INDEX. 



Bronchitis, with dropsy, 619 
Broussais's theory of fever, 58 
Brown's theory of fever, 58 
Brunker, Dr., letter on scarlet fever, 439 
Byrne, Dr., observations on syphilitic bron- 
chitis, 219 
Byron, Dr., letter on scarlet fever, 439 

Cancer of the liver, 664 
Capillary circulation, 400 
Carnrichael, Mr., first introduced the non- 
mercurial treatment of sy- 
philis, 277 
observations on the paraple- 
gia following infantile re- 
mittent fever, 353 
Carpenter, Dr., opinion as to the cause of the 
sensation of Thirst, 81 
opinions concerning capillary 
circulation, 416 
Caries of the bones from syphilis, 296 
Carswell, Dr., opinion on the most frequent 

site of tubercles, 520 
Cases simulating tic douloureux, 551 
Catarrhal affections of the bronchial tubes, 204 
Caustic, mode of applying it in chancres, 323 
Cayol, professor, reference to his Legons 

Orales, 493 
Cemetery, Glassnevin, Interments at, during 

the epidemic of influenza, 465 
Census committee, their statistical report of 

amount of deaths from typhus fever, 54 
Cerebral symptoms in fever, treatment in an- 
ticipation of, 97 
disturbance in fever, use of tartar eme- 
tic and opium in, 121 
Chadwick, Mr., on epidemics among cattle, 55 
Chalybeates in chronic bronchitis, 210 
Chancres, 319 

on the genital organs, 286 
on the predisposition to, 291 
in the throat, 293 
Charite* (Hospital) at Berlin, treatment of 

syphilis in, 307 
Cheyne and Barker, report on fever quoted, 

58 
Cholera, use of acetate of lead and opium in, 

591 
Chorea, 602 

Christison, Dr., remarks on the adulteration 
of the hydriodate of potash, 
40 
on fever, 60 
Chronic bronchitis, use of chalybeates in, 210 
cough, 214 

use of sarsaparilla and nitric 
acid in, 567 
diarrhoea, 569 
disease in fever, vomiting a symptom 

of, 560 
laryngitis, 545 
rheumatism, successful treatment of, 

561 
scrofulous fever, 94 
variety of delirium tremens, 386 
Circulation in acephalous monsters, Dr. Hous- 
ton's paper on this subject, 83 



Circulation, on the powers which cause and re- 
gulate the, 399 
Clarke, Dr., of Rathdrum, letter on scarlatina, 

from, 438 
Clarke, Mr., communication on electro-magne- 
tism, 363 
medical nnd atmospheric electricity, 
368 
Clear sound with solidified lung, 568 
Clifford, Dr., of Trim, letter on scarlatina, 

from, 438 
Clinical instruction, introductory lecture on, 
No. 1, 17 
introductory lecture, No. 2, 

26 
introductory lecture, No. 3, 
35 
Clutterbuck, theory of fever, 58 
Cold applications to the head, 392 
Colds, 104 
Colonies, Major Tulloch's report of the health 

of British troops in, 50 
Condylomata, 291 
Congestion of the intestines, 78 
Connection between diseases of different or- 
gans, 480 
Connor, Dr., of Carlow, letter on scarlatina, 

from, 442 
Constitutional irritation from blisters, 389 
inflammation in general, 490 
Contagion, 61 
Contagion of syphilis, 299 
Continued nervous fever, remarks on, 171 
Contraction and dilatation of the pupil in 

fever, 1 1 5 
Contractility of efferent ducts, 1 93 
Convalescents and fever patients, proper food 

for, 72 
Convulsions in fever, danger of, 158 
Cookson, Mr., account of his attack of fever, 1 32 
Cooper, Sir Astley, on the effects produced by 
tying the vertebral and 
carotid arteries, 117 
on gonorrheal rheumatism, 
272 
Copland's dictionary, extract from, on the use 
of spirit of turpentine in fever with delirium 
and tympanitis, 120 
Copland, Dr., on emetics at the commencement 

of fever, 104 
Corrosive sublimate in syphilis, 330 
Cough from worms, 216 
hysteric, 217 
from venereal taint, 217 
occurring in the gouty habit, 219 
Coup de Soleil, 117 
Cowan, Dr. report on fever, 54 
Croly, Dr., of Mountmellick, letter on scarla- 
tina, from, 443 
Cruveilhier, opinions on the cause of pulmo- 
nary hemorrhage, 239 
Cullen, Dr., theory of fever, 58 
Cumming, Dr., of Armagh, letter on scarla- 
tina, from, 437 

Debilitated heart in fever, an indication for the 
use of wine and stimulants, 166 



INDEX. 



747 



Delirious patients in fever, the management 

of, 90 
Delirium in fever, morbid appearances after, 95 
Dr. Green's letter on the use 
of tartar emetic and opium 
in, 165 
Delirium of fever, use of tartar emetic in, 121, 
131, 137, 142, 153 
and convulsions in jaundice, 394 
traumaticum, 389 
tremens, 685 
Diarrhoea, chronic, utility of persesquinitrate 
of iron in, 569 
of phthisis, 581 
Dietetic management of fever patients, 70 
Difference of opinion respecting the use of 

mercury in syphilis, 317 
Dilatation and contraction of the pupils in 

fever, 117 
Discharges, peculiar alvine, 622 
Disposition to contract syphilis, 301 
Domestic remedies for feverish colds, 104 
Dorpat, mercury seldom used therefor syphilis, 

331 
Dover's powder with hydrarg. c. creta in some 

forms of tympanitis, 78 
Drink, the proper mode of giving in fever, 72 
Dropsy in acute bronchitis, 619 

treatment of, 620 
Ducts, contractibility of the efferent, 193 
Dupuytren, Baron — mode of administering 

opium, 387 
Dyce, Dr., report of fever in Aberdeen Infirm- 
ary, 140 
Dysentery, 576, 695 

subacute, 701 
Dyspepsia, 573 

Earache, preceded by rigors in fever, 558 
Edinburgh — mode of clinical instruction pur- 
sued there, 19 
Education of persons intended for the medical 

profession, 36 
Electro-magnetism, Mr. Clarke's communica- 
tion on, 363 
Emetics at the commencement of fever, 103 
and chalybeates in chronic bronchitis, 
210 
Endocarditis, 656 

Enlargement and inflammation of the liver 
from scarlatina, 484 
of the liver from abuse of mer- 
cury, 482 
from disease of the 
heart, 486 
spleen, 488 
Epidemic of yellow fever in Ireland, 183 
at Gibraltar, 180 
of scarlet fever, 421 
of influenza, 462 
Epidemics, 102 

Eruption from morbid poison similar to syphi- 
litic, 322 
Erysipelas and gangrene, 489 
Essential disease, fever is an, 59 
Exanthematic nature of typhus — Dr. Perry's 
opinion, 62 



Expergefacients in fever, 73 

Eye, phlegmasia dolens of the, 615 

Farcy, glanders, Ac, 606 

Fever, general observations on, 50 

account of the Russian intermittent, 

200 
air of the sick chamber in, 66 
anatomical characters of, 59 
an essential disease, 59 
an exanthematous disease, 62 
application of cold to the head in, HI 
chronic scrofulous, 95 
contagious nature of, 61 
dietetic management in, 70 
Dr. Armstrong's rules for wine in, 

169 
Dr. Stokes's researches on the state of 

the heart in, 166 
earache preceded by rigors in, 558 
emetics in the commencement of, 103 
general treatment of, 69 
intermittent, 196 
lone-continued nervous, remarks on, 

171 
morbid appearances after delirium in 

fever, in, 95 
nervous, Dr. Autenrieth's account of, 

427 
prescriptions in, 175 
proper choice of a nurse in, 65 
proper food for patients labouring 

under, 71 
protest against the use of purgative 

medicines in, 104 
reports of mortality, in Ireland from, 

54 
scarlet, 421 
tertiana soporosa, 200 
thirst frequently depending on the state 

of some internal organ in, 81 
treatment continued, 75 
tympanitis from inattention to diet, and 

purging in, 76 
venesection as a means of checking, 

108 
warm applications strongly recom- 
mended, 112 
wine in, 167 
with cerebral disturbance, use of tartar 

emetic and opium in, 121 
yellow, 179 

at Martinique, 195 
Fletcher, Dr., on epidemics, 65 
Formation of tubercles, 244 
Fothergill, Dr., account of the " Putrid Sore 

Throat," 445 
Fricke, Dr., communication on syphilis, 280 

on the non-mercurial treatment of 
syphilis, 307 
Froriep, Dr. Robert, observations on syphilis, 

277 
Fugitive swellings and pains, 491 
Functional disorders of the brain, 683 

Gangrene of the lungs, 710-718 

and pleurisy, 221 



748 



INDEX. 



Gangrene from erysipelas, 492 
Geoghegan, Dr., letter from, on scarlet fever, 438 
Gibraltar, account of the yellow fever epide- 
mic there in 1828, 180 
Glanders, 606 

Glasnevin Cemetery, report of burials in, dur- 
ing the prevalence of influenza, 465 
Gogerty, Dr., of Nobber, letter on scarlet fever, 

441 
Gonorrhoea, 263 
Gonorrhoea! ophthalmia, 273 
Gout, 493 

affecting the lobe of the ear, 495 
Gouty grinding of the teeth, 496 
neuralgia of the skin, 497 
ramollissement of the spinal marrow, 
501 
Green, Dr. R., of Youghal, letter on tartar 
emetic in the delirium of fever, 165 
Mr., on pseudo and true syphilis, 278 
Griffin, Dr., of Limerick, letter on scarlatina, 

444 
GUnther, Dr., communication on syphilis, 280 
Guthrie, Mr., on the use of lunar caustic in 
purulent ophthalmia, 276 

Haemoptysis, 229 

remarkable instances of recovery 
from, 242 
Hall, Dr. Marshall, theory on the circulation, 

400 
Hamburgh, treatment of syphilis in the hospi- 
tal at, 280 
Hanlon, Dr., of Portarlington, letter on jaun- 
dice, 394 
Harvey, Dr., of Pomeroy, letter on scarlatina, 

442 
Hastings, Dr., reference to his doctrines on the 

capillaries, 400 
Heart, abscess of, 544 
Hennen, Mr., opinions on syphilis referred to, 

260 
Hepatitis, chronic, from disease of the heart, 

486 
Hewson, Mr., opinion on cough from venereal 

taint, 218 
Hiccup in fever, treatment of, 80 
Hoarseness and loss of voice, 582 
Holland, Dr., of London, on influenza, 463 

of Sheffield, experiments on the 
circulation through the capil- 
laries, 420 
Hoskins, Mr., on purulent ophthalmia, 264 
Houston, Dr., account of an acephalous foetus, 
83 
observations on periostitis, 531 
Howship, Mr., on the formation of bone, &c, 

530 
Hudson, Dr., letter on scarlatina, 439 
Hunter, Mr., views on venereal referred to, 

260 
Hutton, Dr., case of paraplegia from irritation 

of urethra, 352 
Huxham, Dr., description of the " Ulcerous 

Sore Throat" 445 
Hypertrophy of the liver produced by scrofula, 

482 



Hypertrophy of the liver from abuse of mer- 
cury, 483 
from scarlatina, 484 
with periostitis, 48 1 
Hypochondriacs, sleeplessness in, 390 
Hysterical ague, 601 

convulsions in jaundice, 399 
Hysteric cough, 217 

Inflammation, and the motor powers which 
cause and regulate the circula- 
tion, 399 
of serous membranes, 641 
of the brain (scrofulous), 94 
Influenza, 462 

Injections, combined with general and local 
means in gonorrhoea, 269 
in gonorrhoea, directions for using, 
267 
Insidious character of the spotted fever epide- 
mic in Dublin, in 1834-5, 135 
Intermittent fever, remarks on, 196 
(Russian), 199 
treatment of, 201 
Intestinal inflammation with tympanitis, 78 
Intestines, congestion of, 79 

observations on the secretion of air 
from, in certain bronchitic affec- 
tions, 206 
use of air in, 77 
Introductory lecture, No. 1,17 
2,26 
3,35 
Iritis, case of syphilitic, 564 

use of turpentine in, 80 
Iron, persesquinitrate of, in chronic diarrhoea, 
569 

Jaundice, 726 

hysterical convulsions, delirium, &c, 

in, 399 
supervention of nervous symptoms 

in, 394 
with arthritis and urticaria, 480, 553 

Laryngitis, 727 

(chronic), 545 
Latent ulceration of the intestines, 580 
Lawrence's account of yellow fever quoted, 191 
Lead, acetate of, in the tympanitis of fever, ac- 
companied by intestinal con- 
gestion, 79 
in Asiatic cholera, 589 
Liniment, St. John Long's, formula for, 212 
Lobelia, the etherial tincture of, recommended 

by Dr. Blakiston in influenza, 479 
Louis, M., researches on yellow fever, 180 
Lungs, mercury in scrofulous affections of the, 
510 

Malaria, Major Tulloch's report on, 50 

Management of delirious patients in fever, 
91 

Marrow (spinal), gouty ramollissement of the, 
501 

Martinique, account of the yellow fever epide- 
mic there in 1839, 1840, 1841, 195 



INDEX. 



749 



Mayo, Mr., observations on the state of the 

pupil in sleep, 88 
Measles in adults and children, 635 
Melsena, 623 

Memorandum of Dr. Fricke's practical obser- 
vations on the nature and treatment of sy- 
philitic diseases, 294 
Meningitis, acute, 665 

chronic, 672 
Mercury, ahuse of, 319 

difference of opinion respecting the 

use of, in the venereal disease, 316 

great utility of the local application 

of, 562 
in phagedena, Dr. Tuohill's commu- 
nication on this subject, 332 
in scrofulous affections of the lung, 

511 
its supposed anti-febrile properties 
questioned, 129 
Mobility of the sternum, a remarkable case of, 

593 
Mode of applying leeches when pneumonia or 
hepatitis supervenes on 
fever, 110 
caustic to venereal sores, 
323 
Morbid appearances after delirium in fever, 95 
Mortality from fever in the province of Lein- 

ster, 54 
Motor powers which cause and regulate the 

circulation, 399 
Muller, professor, opinions on the circulation 

through the capillaries, 85 
Munk, Dr., communication on the use of mer- 
cury in scrofulous affections of the lung, 
515 

Narcotism, efficacy of green tea in, 73 

Nervous extremities, disturbance of, giving rise 
to subsultus tendinum, 92 
symptoms in jaundice, danger of, 394 

Neuralgia, gouty, of the skin, 497 

New views upon the use of tartar emetic in 
fever, 131 

Nitric acid with sarsaparilla in chronic cough, 
567 

Nolan, Dr., letter on the use of opium in peri- 
toneal inflammation, 141 

Non-mercurial treatment of syphilis, 260 

Nose, bleeding from, in scarlatina, fatal case 
of, 448 

Notes of clinical lectures delivered in 1826, on 
yellow fever, 192 

Nurse and assistants for fever patients, proper 
choice of, 66 

O'Beirne, Dr., plan of rapid mercurialization 

in scrofulous affections of the joints, 51 1 
O'Brien, Dr., letter on scarlatina, 443 
Observations on the secretion of air from the 
alimentary mucous membrane in certain 
pulmonary complaints, 206 
O'Ferrall, Mr., letter on scarlatina, 434 
Ophthalmia (purulent), Mr. Hoskin's observa- 
tions on, 264 
gonorrhoeal, 271 



Opium and tartar emetic, utility of, in certain 
forms of fever, 121 
and wine in fever, 169 
flagellation effectual in poisoning from, 

73 
with acetate of lead in cholera, 589 
Oppenheim, Dr., researches on syphilis, 297 
Oris cancrum, case of, with remarks, 597 
Osbrey, Dr., account of the scarlatina observed 

at St. Mary's parochial dispensary, 450 
Over-dosing with purgatives in fever, protest 
against, 105 

Paralysis, agitans, 603 

lecture on, 342 

new views on this subject, 343 
pathology of, 343 
Paraplegia from disease of urinary organs, Mr. 
Stanley's cases of, 
343 
kidneys, Dr. Stokes's 
case, 350 
enteritis, 346 

irritation of urethra, Dr. Hut- 
ton's case, 352 
lead, Dr. Bright's observation 

on, 350 
poisoning by arsenic, Orfila's 
experiments, 350 
following remittent gastric fever of 
infants, Mr. Carmichael's observa- 
tions on, 353 
metritis, 352 
varieties of, 343 
Pathology and treatment of syphilis, 276 
Peculiar alvine discharges, 622 
Pericarditis, 542, 650 
Periostitis, 529 

scrofulous, occurring in persons 
previously affected with chancres, 
importance of a correct diagnosis 
in such cases, 340 
Peritonitis, 664 

tubercular, 648 
Perry, Dr., of Glasgow, on the exanthematous 

nature of typhus fever, 62 
Phagedena, Dr. Tuohill's communication on 
the proper period for giving mercury in, 332 
Phlebitis, 594 
Phlegmasia dolens, 614 

of the eye, 6 1 5 
pathology of, 594 
Phthisis, mortality from, as compared with 
other diseases, 244 
pathology of, 244 
pulmonalis, 705, 713-720 
senilis, 579 
Pirogoff's " Surgical Annals" (on venereal"), 

331 
Pleurisy, 644 

Pleuritis and gangrene of the lung, 221 
Pleuro-pneumonia, 541,577 
Pneumonia, 227, 723 
Poisoning from opium, flagellation effectual 

in, 73 
Poisons capable of producing eruptions similar 
to syphilis, 322 



750 



INDEX. 



Predisposition to chancres, 291 
Prescriptions in fever, 175 
Proper choice of nurse and assistants in fever, 
66 
food for fever patients and convales- 
cents, 66 
Prurigo, 548 
Psoriasis, 575 
Pulmonary apoplexy, 232 

from syphilitic taint, 217 
without haemoptysis, a 
remarkable case of, 
232 
irritation connected with a gouty dia- 
thesis, 219 
Pulse, disproportion between it and respiration, 

remarkable case of, 209 
Pupil, Mr. Mayo on the state of, during sleep, 

88 
Pupil's contraction and dilatation, 116 
Purgative medicines, remarks on, 384 
Purulent ophthalmia, Mr. Hoskins on, 264 

Quinine, sulphate of, probably first used in 
Ireland in ague by the author, 51 

Ramollissement of the spinal marrow, from 

gout, 501 
Recovery, remarkable instances of, from hae- 
moptysis, 242 
Reports of the mortality from fever in Ireland, 
54 
on statistics of fever, Dr. Cowan's, 54 
on syphilis by Dr. Roe, 260 
Result of Dr. Oppenheim's inquiries on syphi- 
lis, 309 
Rheumatism, acute, 627 
chronic, 560 
gonorrhoea!, 271 
Ridley, Dr., letter on scarlatina, 439 
Roe, Dr., report on syphilis, 260 
letter on scarlatina, 444 
Russell, Dr., on do., 443 
Russian intermittent fever, 196 

Scarlet fever, 421 

Dr. Connor's letter on, 442 
Dr. Griffin's do., 444 
Dr. Lloyd's do., 438 

Dr. Long's do., 442 

Dr. O'Brien's do., 443 
Dr. Ridley's do., 439 
Dr. Roe's do., 444 

Dr. Ru>se!l's do., 443 
Dr. Osbrey's account of, as ob- 
served at St. Mary's Dispen- 
sary, 450 
Mr. O'Ferrall's communication, 

434 
Professor Porter's remarkable 
case of, 44 1 
Scrofulous affections of the lung, use of mer- 
cury in, 51 1 
fever (chronic), 94 
inflammation of the brain, 94 
Secondary syphilis, 321 
Sedatives in fever, remarks on, 72 



Sensation of tickling which precedes cough, 

216 
Sleeplessness from anxiety, grief, &c, 383 
from irritation of blisters, 389 
in delirium tremens, 385 
in fever, 386 

in hypochondriacs and hysterical 
patients, 390 
Softening of the brain, 679 
Solidified lung yielding clear sounds on per- 
cussion, 567 
Sores (venereal), mode of applying caustic to, 

323 
Sore throat (venereal), 293 
Spirit of turpentine in flatulent distension of 
the stomach accompanied 
with delirium, coma, &c, 
119 
opinion of Dr. Copland on 
the efficacy of this treat- 
ment in the above cases, 
120 
in iritis, 80 

in tympanitis accompanied 
by intestinal inflamma- 
tion, 78 
Spleen, enlargement of, 488 

powder, composition of, 602 
Spotted fever epidemic in Dublin in 1834-5, 

account of, 135 
Staberoh, Dr., opinions on the treatment of 

syphilis, 310 
Stammering, observations on, 582 

suddenly stopping on the super- 
vention of laryngitis, a case of, 
583 
Stanley, Mr., observations on paralysis from 

disease of the urinary organs, 343 
Starvation system in fever, productive of or- 
ganic disease, 70 
State of the heart in fever as an indication for 
administering wine, Dr. Stokes's researches 
on, 166 
Statistical reports on fever, by Dr. Cowan, 

54 
Stephenson, Mr., his own case of fever, 133 
Sternum, remarkable mobility of, 593 
St. John Long's liniment, 212 
Stokes, Dr., observations on paralysis following 
enteritis, 346 
protest against purging in fever, 76 
on the treatment of hiccup in fever, 

80 
researches on the state of the heart 
in fever, 166 
Struntz, Dr., on the non-mercurial treatment 

of syphilis, 307 
Subsultus tendinurn, sometimes from disturb- 
ance of the nervous extremities, 92 
Superficial ulceration of the legs combined 

with enlarged spleen, 488 
Syphilis, 260 

Dr. Roe's report on, 260 

Dr. Struntz's observations on the 

non-mercuiial treatment of, 307 
on the pathology and treatment of, 
276 



INDEX. 



751 



Syphilis, treatment of at the General Surgical 

Hospital at Hamburgh, 280 
Syphilitic eruptions, different forms of, 294 
iritis, action of belladonna in, 664 

Tartar emetic and opium in fever, 121 

in the form of enema, advan- 
tages of, 91 
Tertiana soporosa, case of, 200 
Therapeutical principles in the treatment of 

syphilis, 304 
Thirst in fever, best mode of allaying it, 72 

frequently dependent on the 
state of some internal organ, 
81 
Thyroid gland, newly-observed affection of, 

570 
Tic douloureux, cases simulating, 551 
Treatment in anticipation of cerebral symptoms 
in fever, 98 
of typhus fever, 75 
Tuberculous meningitis, 656 
Turpentine extremely useful in the tympanitis 
of fever, 78 
in flatulent distension of the abdo- 
men accompanied by delirium 
and coma, 119 
in iritis, 80 
Tympanitis in the middle stage of fever often 
arises from intestinal congestion, 
78 
treatment, acetate of lead recom- 
mended, 79 



Tympanitis often the consequence of inatten- 
tion to diet, or over-dosing with 
purgatives, 76 
with intestinal inflammation, treat- 
ment of, 80 
Typhus and typhoid fever, 730-736 
fever, an essential disease, 59 

Urticaria from eating the Otaheitan eel and 
certain other kinds of food, 555 
with jaundice and arthritis, 553 
Use and abuse of mercury in syphilis, with 
cases, 324 

Various cautions respecting leeches and cup- 
ping-glasses, 1 10 
Velpeau's method of treating sore throat, 585 
Venereal sore throat, 293 
Venesection as a means of checking fever, 108 
Vomiting and purging at the commencement 
of fever, 93 
considered as a symptom of fever, 
560 

Warm applications to the head recommended, 

Wilde, Mr., report on fever, 54 
Wine and opium in fever, 169 

in fever, 166 
Worms in the intestines producing cough, 217 

Yellow fever in Dublin, account of, 183 
Gibraltar, 179 



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